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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/29/2021
Date Signed: 06/29/2021 06:03:14 PM

Document Has Been Signed on 06/29/2021 06:03 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 VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR:WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(818) 359-9447
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 49CENSUS: 24DATE:
06/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Evangeline Ward-MichaylukTIME COMPLETED:
01:00 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control #29-AS-20210628115658 investigation visits conducted on 6/29/21.

Interview with Administrator starting at 11:12 am revealed that they told resident #1 (R1)'s conservator that their van was broken so they could not provide transportation for R1's medical appointment. Administrator stated that they told R1's conservator that they would have to make transportation arrangements for R1's medical appointment. Administrator stated that the van has not been working since August 2020 and they do not know what is wrong with it. Administrator stated that they have not had residents and/or their responsible persons sign a new Admission Agreement under the new facility Ventura Villa Assisted Living. LPA advised Administrator that they will need to follow the existing Admission Agreements under Treacy Villa #56170345 until the new signed Admission Agreements are received.

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


Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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 06/29/2021 06:03 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/29/2021 at 01:15 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 VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/06/2021
Section Cited
CCR
87312

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87312 Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition.
This requirement is not met as evidenced by:
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Administrator stated that the will be making arrangements for medical transport for residents medical/dental appointments. Administrator stated that they will provide documentation of arrangements with medical transport company to CCL by 7/6/21.
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Based on interviews, the licensee did not comply with the section cited above as the facility van is not maintained in a safe operating condition which poses a potential safety and personal rights risk to persons in care.
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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:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021


LIC809 (FAS) - (06/04)
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