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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850301
Report Date: 09/18/2023
Date Signed: 09/18/2023 02:46:10 PM

Document Has Been Signed on 09/18/2023 02:46 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:VILLARIANA CAREFACILITY NUMBER:
565850301
ADMINISTRATOR:BUSCH, HELEN ROSE T.FACILITY TYPE:
740
ADDRESS:4731 READING DRIVETELEPHONE:
(319) 360-1230
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 3DATE:
09/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Johnna Uddeh - Assistant AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Incident Visit to follow up on a LIC624A Death Report received by the department on 09/11/2023. LPA met with Johnna Uddeh - Assistant Administrator and explained the reason for the visit.

On 09/11/2023, the department reviewed a copy of LIC624A for Resident #1 (R1) along with a copy of the Death Certificate, which indicated R1 passed away on 08/22/2023 at 07:40 am. R1's Death Certificate listed the sequential causation of the immediate cause of death as follows: severe sepsis, pneumonia Organism unspecified that led to Acute respiratory failure, which was the immediate cause of R1's death.

At approx 10:00am, LPA conducted physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation. LPA did not observe any immediate or potential health and safety concerns at this time.

The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
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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