<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 09/06/2022
Date Signed: 09/06/2022 07:50:52 PM

Document Has Been Signed on 09/06/2022 07:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VENTURA GRAND CHATEAUFACILITY NUMBER:
565802472
ADMINISTRATOR:MARK DEN PERALTAFACILITY TYPE:
740
ADDRESS:5430 TELEGRAPH ROADTELEPHONE:
(805) 642-2567
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 49CENSUS: 37DATE:
09/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Amy PhillipsTIME COMPLETED:
05:27 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek conducted a case management - deficiencies visit to address deficiencies observed. LPA arrived at the facility at 02:30PM and met with Medication Technician Amy Phillips. Administrator was unavailable during today's visit, but was contacted by telephone and designated Amy Phillips to sign today's reports. Entrance interview conducted.

During today's visit, a facility tour was conducted beginning at 02:38PM and LPA interviewed staff at 02:35PM and 02:45PM. It was observed that the facility's air conditioning was broken and the incident was not reported to CCL as of today's date.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted with Medication Technician Amy Phillips. Today’s reports and appeal rights were reviewed and provided to the Administrator via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/06/2022 07:50 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/06/2022 at 04:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA GRAND CHATEAU
FACILITY NUMBER: 565802472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2022
Section Cited
CCR
87211(a)(1)(D)

1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...the following: (1) A written report shall be submitted to the licensing agency...within seven days...(D) Any incident which threatens the welfare, safety or health of any resident...absence of the resident.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide vendorized training to those responsible for reporting incidents to CCL and send evidence of training to CCL to include name of trainer, date & time of training, roster of atendees, and topics discussed on or before 09/20/2022.
8
9
10
11
12
13
14
Based on observation and interview, the facility's air conditioning has been broken since 08/29/2022 and was not reported to CCL as of today's date, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2