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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 08/17/2023
Date Signed: 08/17/2023 05:34:54 PM

Document Has Been Signed on 08/17/2023 05:34 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 NORTH, 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:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 49CENSUS: 16DATE:
08/17/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angelica Arambulo- Office ManagerTIME COMPLETED:
05:40 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 06/15/2023. The LPA was greeted by Med Tech Dora Islas and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly.

Today the LPA conducted a file review, a medication audit, four (4) resident and three (3) staff interviews.
Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of sixteen (16) Resident Files. The following was noted: Resident #1’s (R1’s) file was observed to be missing their functional capability assessment, R2’s file was observed to be missing a preplacement appraisal, and R3 and R4’s file was observed to be missing their personal rights (LIC613). The LPA reviewed five (5) of twenty-one (21) staff files. The following was noted: One staff (S1) file out of five was observed to be missing a first aid certificate, health screening, and documentation of Tuberculosis. Four out of five staff files (S1, S2, S3, S4) were missing four hours of training which shall be specific to postural supports, restricted health conditions and hospice care. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 5/26/2023). The LPA obtained Resident and Staff Rosters.
Medications: At 1:30 p.m. a medications review was initiated. The following was observed: R1’s Expiration date and date filled for Nifedipine ER did not match the Facility Centrally Stored Medication and Destruction Record (CSMDR), R2’s expiration date and date filled for Losartan POT and Memantine HCL did not match the CSMDR, and R3’s CSMDR records were observed to be missing. R3’s Risperidone medication was counted in front of the LPA and was observed to have three more pills than needed based on the quantity on the medication’s label, in addition on the Medication Administration Record, medication for August 14, 2023 was unaccounted for. Upon observation, Med Tech Dora initiated correcting all of the missing information for residents (R1,R2, and R3).
Interviews: During the visit the LPA conducted four (4) resident Interviews and three staff interviews
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 to Office Manager Angelica.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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 4
Document Has Been Signed on 08/17/2023 05:34 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/17/2023 at 04:15 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

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 in one staff (S1) out of five staff as S1 does not have a health screening on their file with their tuberculosis (TB) information which poses a potential health and safety risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Office Manager agrees to submit proof of health screening and TB for S1 by 8/24/23 and S1 cannot work at the facility until TB documentation is presented.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in three out of five staff did were missing four hours of trainning specific to postural supports, restricted health conditions and hospice carere which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Office Manager agrees to submit proof that all staff has completed all necessary dementia training and submit proof to CCL by 8/31/23.
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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/17/2023 05:34 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/17/2023 at 04:15 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: 08/17/2023

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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Based on record review, the licensee did not comply with the section cited above as Resident #1’s (R1’s) file was observed to be missing their functional capability assessment, R2’s file was observed to be missing a preplacement appraisal, and R3 and R4’s file was observed to be missing their personal rights (LIC613) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Office Manager agrees to make sure all resident files observed are complete and current and submit proof to CCL by 8/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/17/2023 05:34 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/17/2023 at 04:33 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(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 interview and record review, the licensee did not comply with the section cited above as R3’s Risperidone medication was counted in front of the LPA and was observed to have three more pills than needed,in addition on the MAR, medication for August 14, 2023 was unaccounted for, and medication information was missing on the CSDMR for R1, R2 and R3, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Upon observation Med Tech Dora started to document all of the observed misiing information.Licensee agrees to complete a medication audit to ensure all medications are properly documented. Complete audit by 8/24/2023 and informed CCL when audit is complete not later than the POC due date. Licensee also agrees to complete staff training around documenting, and assisting with medications and to ensure consistency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4