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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800682
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:26:39 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220707103747
FACILITY NAME:ALMAVIA OF CAMARILLOFACILITY NUMBER:
565800682
ADMINISTRATOR:MATTHEW HATHWAYFACILITY TYPE:
740
ADDRESS:2500 NORTH PONDEROSA DRIVETELEPHONE:
(805) 388-5277
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:100CENSUS: 76DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Matthew HathwayTIME COMPLETED:
01:06 PM
ALLEGATION(S):
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illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 11:09AM and met with Executive Director Matthew Hathway. Entrance interview conducted.

During today's visit, LPA interviewed Executive Director at 11:10AM, spoke with Resident #1(R1)'s family member at 11:35AM, interviewed staff at 12:15PM, toured the facility with Administrator at 12:25PM, and LPA gathered copies of pertinent documents. The following was then concluded:

Interview revealed that R1 has not been evicted from the facility. LPA confirmed R1's room at the facility is labeled, furnished and contains R1's personal belongings. R1 is listed on the current census provided during the visit. R1 is currently hospitalized and awaiting transfer to a higher level of care prior to returning to the facility. R1's family member stated that R1 is not evicted and is able to come back to the facility. Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20220707103747
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682
VISIT DATE: 07/14/2022
NARRATIVE
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Interview and record review revealed that R1 has been living at the facility for over a year and was independent at the time of move in. Around the end of May 2022, R1 had an incident which required hospitalization. R1 returned to the facility and required additional care and supervision at that time. R1 was again hospitalized and has yet to return to the facility. Due to the change in condition, R1 requires additional care and supervision. At this time R1 has not returned yet, but will be able to once R1's condition is stabilized. R1's family member stated a Memory Care unit would be more appropriate for R1 and the plan is to move R1 to a facility with an available Memory Care room at the time of discharge from the hospital. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore, the allegation "illegal eviction" is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of this report was provided via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
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