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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802472
Report Date: 01/26/2024
Date Signed: 01/26/2024 05:17:21 PM

Document Has Been Signed on 01/26/2024 05:17 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VENTURA GRAND CHATEAUFACILITY NUMBER:
565802472
ADMINISTRATOR:MICHAEL DIMAGUILAFACILITY TYPE:
740
ADDRESS:5430 TELEGRAPH ROADTELEPHONE:
(805) 642-2567
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 49CENSUS: 37DATE:
01/26/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jennifer Diaz-MT TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 12/21/2023. The LPA was greeted by MedTech Jennifer Diaz and informed them of the reason for the visit. Administrator Sean Beharry could not be present during the visit today and authorized MT Hazel Aspillaga to review and sign the report.

Today the LPA conducted a medication audit, interviewed three staff, and finished the record review initiated on 12/21/2023.
Interviews: During today’s visit, the LPA conducted three (3) staff interviews. Medications: At 1:45 p.m. a medications review was initiated for three out of five residents and the following was observed. The medications were stored in the medication room, which is locked and inaccessible to the residents. During Resident #3 (R#3's) audit, the LPA observed Donepezil HCL 5MG Tab still in the bubble pack, however the plastic bubble was punched out but medication not successfully poured out. MT Jennifer Diaz stated that when medication is not given it will be documented on the Medication Administration Record (MAR). However there was no documentation on R3’s MAR that the medication was not given. Record Review: The LPA observed documentation of Infection Control plan, Disaster prevention and Insurance liability. The LPA reviewed five (5) out of thirty-seven (37) resident files. The LPA was not able to review any of the five residents’ admissions agreements, due to them being stored in a separate file in the Administrators office. The administrator was not available for todays visit, and staff does not have access to the office. Out of the five files reviewed, the LPA identified that three files were missing the safeguards for property/valuables form, (SPV), two residents (R2,R5) did not have signed resident rights forms (LIC613), and three residents (R2, R3, R4) did not have their appraisal/needs and services form (LIC625) signed by the resident and/or their responsible party.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2024 05:17 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/26/2024 at 04:35 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as medication for R3 was not given 1/22/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2024
Plan of Correction
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2
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4
Administrator agreed to conduct medication training for all MedTechs and submit proof to LPA by no later than end of day 1/30/24
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 01/26/2024 05:17 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/26/2024 at 04:35 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: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in as LPA could not review admissions agreements, and 3 residents were missing SPV forms, 2 residents did not have signed resident rights forms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Administrator has agreed to do the following:
1. Obtain signed resident rights forms LIC613 for the two resident.
2. Obtain missing SPV forms for three residetnts.
3. Submit a statement of understanding of reg 87506 and that forms have been obtained.Submit to LPA by 2/9/24.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024


LIC809 (FAS) - (06/04)
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