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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800682
Report Date: 11/09/2022
Date Signed: 11/10/2022 08:34:26 AM


Document Has Been Signed on 11/10/2022 08:34 AM - 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: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: 73DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Erika Miller, Julie Downs, Sarah StichlerTIME COMPLETED:
03:51 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 12:20PM for an unannounced annual inspection. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPA initially met with Administrative Services Director Sarah Stichler. LPA then met with Resident Care Director Erika Miller and Memory Care Director Julie Downs. Entrance interview conducted.

Beginning at 12:49PM, the LPA, along with Community Directors, 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 following was observed:

Annual fire sprinkler inspection was completed on 03/03/2022. No safety concerns were noted at that time. Fire extinguishers throughout the building were observed to be fully charged and are serviced annually.



COMMON AREAS: The facility is a two story building. The facility contains multiple common areas, which were all observed to be clean, furnished appropriately and in good condition at the time of the visit. There were no obstructions and/or tripping hazards throughout the facility. Allrequired postings were observed in the common areas on the first floor.

The LPA and Community Directors toured the outside area of the facility: two are designated for Memory Care residents and the other two are designated for Assisted Living residents. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents.

MEMORY CARE: Memory Care is located on the first floor and has 18 (eighteen) rooms. Resident bedrooms are single and double occupancy with private bathrooms. A random sampling of 2 (two) resident rooms were observed to be furnished appropriately. Bathrooms were observed to be safe and sanitary with
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682
VISIT DATE: 11/09/2022
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grab bars and non-skid mats. Hot water was measured in both observed resident rooms and tested within the required range of 105 to 120 degrees Fahrenheit. Medications for the memory care unit are centrally stored and locked in the medication room. The indoor and outdoor areas of the memory unit are secured with a delayed egress system. There are two outdoor gated courtyards designated for Memory Care. LPA observed sufficient outdoor furnishings and shaded outdoor space.

RESIDENT ROOMS: There are 60 Assisted Living units and can be found on the first and second floors of the building. Assisted Living units are equipped with a refrigerator, sink, and microwave and contain private restrooms. A random selection of two resident rooms were observed. Residents rooms were observed to be furnished appropriately and contained appropriate bedding/linens. Bathrooms were observed to be safe and sanitary with grab bars and non-skid mats. Water temperature was checked in both randomly selected rooms in the Assisted Living unit and measured within the required range of 105 to 120 degrees Fahrenheit.

KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. LPA observed sufficient perishable and non-perishable foods to meet the minimum two-day and seven-day emergency supply of food and water.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Resident Care Director and Memory Care Director regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

RECORD REVIEW: During today's visit, LPA reviewed facility Guardian roster. Staff #1 (S1) was previously employed at the facility, was separated from employment on 12/19/2021. Then S1 returned to work in early 2022 but background clearance was not re-associated to the facility at that time.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/10/2022 08:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 in Staff #1 (S1) had been employed at the facility and received criminal record clearance, was separated from employment and returned, but criminal record clearance was never reassociated to the facility which poses an immediate safety risk to persons in care.
POC Due Date: 11/09/2022
Plan of Correction
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Admistrative Services Director reassociated S1 to the facility during today's visit prior to S1 returning to work. POC cleared.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682
VISIT DATE: 11/09/2022
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil Penalty assessed in the amount of $500. Community Directors were informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted with Community Directors Julie Downs, Erika Miller, and Sarah Stichler. Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4