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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850093
Report Date: 06/23/2025
Date Signed: 06/23/2025 04:25:20 PM

Document Has Been Signed on 06/23/2025 04:25 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 VILLA ASSISTED LIVINGFACILITY NUMBER:
565850093
ADMINISTRATOR/
DIRECTOR:		WARD-MICHAYLUK, EVANGELINEFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA ROADTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 49CENSUS: 20DATE:
06/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Angelica ArumbuloTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual inspection. LPA met with Operations Manager Angelica Arambulo and explained the reason for the visit.

LPA, along with the Manager, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility's last fire inspection was completed on 1/28/2025 with no concerns noted. LPA tested the carbon monoxide detector which functioned properly during the visit. Fire extinguishers appeared fully charged and were last serviced 12/2024.

RESIDENT ROOMS/RESTROOMS: Resident rooms are either single or double occupancy. 10 (ten) resident rooms were observed during today's visit and contained the appropriate furnishings, linens, and bedding. Resident restrooms are jack-and-jill style - shared between 2 adjacent rooms. Restrooms observed were clean and sanitary in operating condition. Water temperature was tested in a sample of resident restrooms and measured at 106.1 degrees Fahrenheit which is within the required range of 105*F-120*F.

COMMON AREAS: Laundry room door lock was broken at the time of the visit. Laundry detergent was observed to be accessible in the laundry room. The facility has shower rooms for residents with non-slip surfaces. LPA observed the surfaces were not non-slip when wet. The Manager stated they would get non-slip mats for the shower rooms.

KITCHEN/DINING ROOM: The dining room was properly furnished and is also utilized as an activity area. The facility had a sufficient supply of food (perishable and non-perishable) and water. Kitchen appliances appeared functional.

(continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VENTURA VILLA ASSISTED LIVING
FACILITY NUMBER: 565850093
VISIT DATE: 06/23/2025
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(continued from LIC809)

BUILDINGS AND GROUNDS: This facility is fully fenced and has a fire clearance for secured perimeter. There is covered seating on the patio for residents' use.

STAFF: LPA spoke with three (3) staff; there were no concerns noted. LPA reviewed five (5) staff files and all were complete. Documents reviewed included, but were not limited to, training records, TB test results, health screenings, and fingerprint background clearance.

RESIDENTS: LPA attempted interviews with residents, however due to cognitive decline was not able to complete the interviews. LPA reviewed five residents' files and all were complete. Documents reviewed included, but were not limited to, physician's reports, admission agreements, personal rights, and needs and services plans.

MEDICATIONS: LPA reviewed medications which are stored in the locked medication room. The facility utilizes Medication Administration Records (MAR) to ensure medications are given correctly. The facility has Centrally Stored Medication and Destruction Records (CSMDR) created by the pharmacies, however the start dates for medications were not transferred to these forms. The Medication Technician was informed these dates must be transferred to the CSMDR. Otherwise, the medications reviewed appeared to be given as prescribed and the medications were properly labeled. The first aid kit is also stored in the locked medication room.


The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of today's report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Teresa Camara
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/23/2025 04:25 PM - It Cannot Be Edited


Created By: Teresa Camara On 06/23/2025 at 04:09 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: 06/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The laundry room door lock was broken and there was laundry detergent left accessible in the laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2025
Plan of Correction
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Licensee representative removed the laundry soap in the unlocked room and placed it in the locked janitorial room. The lock on the laundry room door will be repaired by 6/30/2025.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Teresa Camara
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2025


LIC809 (FAS) - (06/04)
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