Ventura Villa Assisted Living

Licensee reports required by licensing agency

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:This requirement is not met as evidenced by: Based on interview conducted and records reviewed, the licensee did not comply with the section cited above as they did not submit an outbreak incident report within 24 hours and a death report within seven (7) days which poses an immediate health and safety risk to resident(s) in care.

Ensure hazardous items are locked and not unattended

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.

Based on observation and record review, the licensee did not comply with the section cited above as 1 (one) out of 4 (four) staff whose records were reviewed did not have criminal record clearance, which poses an immediate health and safety risk to persons in care.

Notify agency before locking doors or gates

Based on observation, the licensee did not comply with the section cited above as both laundry room and staff room door locks were observed to be broken and unusable; laundry room contained accessible laundry detergent, staff room contained accessible staff personal belongings, including a visible medication bottle, which poses an immediate health and safety risk to persons in care.

§1569.69(a) (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...This requirement is not met as evidenced by: Based on interviews, the licensee failed to comply with the section cited above as caregivers without complete medication training are passing medications, & training consultants inormation was not available which poses a potential health and safety risk to persons in care.

Protection from punishment and intimidation

87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by: Based on Records obtained. The licensee did not comply with the above cited section as R1 was held down by a visitor and S1 and S2 changed R1 infront of the visitor which poses an immidiate personal rights risk to residents in care.

Resident record must include minimum required items

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.

Include hazardous health condition records

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.

Assist residents with self-administered medication

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.

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.

Provide resident hot water for personal care

Based on observation the licensee did not comply with the section cited above in two (2) of two (2) resident bathrooms water temperature was observed to be 97.2 degrees and 99.1 Fahrenheit which poses an immediate health and safety risk to persons in care.

Food quality controls and rejected damaged goods

Based on observation, the licensee did not comply with the section cited above as five (5) food items in the food pantry were expired which poses an immediate health and safety risk to persons in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in R1 falling and sustaining injuries, which poses an immediate health and safety risk to residents in care.

87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures. … For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1).This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility did not call 9-1-1 and instead called R1's hospice agency after R1 fell and was in pain, even though the pain was unrelated to the terminal illness, which poses an immediate health and safety risk to residents in care.

1569.269(a)(20) Enumerated rights; severability. To select their own physicians, pharmacies, privately paid personal assistants, hospice agency... in a manner that is consistent with the resident’s contract of admission or other rules of the facility, and in accordance with this act. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee requested a change in Physical Therapist companies without prior notification to responsible parties which posed a potential personal

Based on observation and record review, the licensee did not comply with the section cited above as both the linen closet containing shampoo & body wash, peri-rinse, Jergens lotion and a supply closet containing personal care items were left unlocked and 1 of 3 residents' records reviewed indicated they are "at risk if allowed direct access to personal grooming and hygiene items" which poses an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in one of 3 records reviewed, the resident has a diagnosis of dementia and the last physician's report was incomplete and dated 04/07/2021 which poses a potential health risk to persons in care.

Provide resident hot water for personal care

Based on observation, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms water temperature was observed to be 99.8 degrees Fahrenheit and 102.5 degrees Fahrenheit which poses an immediate health risk to persons in care.

Keep window screens clean and in repair

87303(c) Personal Accommodations and Services. Individual privacy shall be provided in all toilet, bath and shower areas.This requirement is not met as evidenced by: LPA observed several resident bathrooms that lacked locks on bathroom doors. These are "Jack and Jill" style bathrooms where adjoining rooms use the same bathroom and can enter when someone else is using the bathroom, which poses a potential health and safety risk to residents in care.

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation, during facility tour, resident restroom was observed to be dirty, which poses an immediate health risk to residents in care.

87705(f)(1) (f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on observation, during facility tour, a closet containing facility electrical equipment was observed to be unlocked and unable to be closed, which poses an immediate health and safety risk to residents in care.

1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 2 out of 6 staff records which poses a potential health and safety risk to persons in care.

First aid training requirements

87411 Personnel Requirements – General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 3 out of 6 staff records which poses a potential health and safety risk to persons in care.

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 2 out of 6 resident records which poses a potential health and safety risk to persons in care.

87458 Medical Assessment. (b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions…This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 3 out of 6 resident records which poses a potential health and safety risk to persons in care.

Health screening and fitness requirements

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health… Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to…This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff records which poses a potential health and safety risk to persons in care.

1569.269 Enumerated rights; severability (a)(30) To keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money, unless limited by statute or regulation.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as staff removed R1’s personal items from their room which poses a potential personal rights risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication,...and toxic substances....This requirement is not met as evidenced by: Based on observation, the licensee failed to comply with the citation above as there are residents with a dementia diagnosis and over the counter medications and hygiene supplies were being stored in an unlocked storage closet which poses an immediate health risk to residents in care.

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: Based on interviews, the licensee did not comply with the section cited above as licensee did not verify that S1's vehicle was maintained in a safe operating condition prior to transporting R1 which posed a potential safety and personal rights risk to persons in care.

Provide assistance for residents medical needs

87465 Incidental Medical and Dental Care (a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation...In providing transportation the licensee shall do so directly or make arrangements for this service.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the facility did not make transportation arrangements for R1's medical appointment which poses a potential personal rights risk to persons in care.

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: 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.