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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800682
Report Date: 08/25/2026
Date Signed: 08/25/2026 02:54:46 PM

Document Has Been Signed on 08/25/2026 02:54 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:ALMAVIA OF CAMARILLOFACILITY NUMBER:
565800682
ADMINISTRATOR/
DIRECTOR:		MICHELE JOHNSONFACILITY TYPE:
740
ADDRESS:2500 NORTH PONDEROSA DRIVETELEPHONE:
(805) 388-5277
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 100CENSUS: 53DATE:
08/25/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Sarah StichlerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway initiated an unannounced Case Management – Incident visit for an incident that was self-reported. Upon arrival LPA met with the Administrative Services Director (ASD), Sarah Stichler. Executive Director (ED), Michele Johnson, was unavailable during today's visit, however ASD is authorized to sign today's reports. Entrance interview conducted.

The Woodland Hills Regional Office (RO) received an incident report via email on 07/30/2026 at 3:22 P.M. stating that on 07/27/2026, Resident #1 (R1) left the facility unassisted through the side exit egress door in the Memory Care unit. LPA Byrne, conducted a telephone call with the facility ED at 3:13 P.M. on 07/31/2026. During the telephone conversation, ED explained to the LPA that R1, who is a newer resident in the facility, was observed at approximately 8:45 P.M. walking around the unit. At approximately 9:00 P.M., after checking all common areas including R1’s room, staff realized that R1 was not present in the facility and that a secure egress door had been left unarmed. Interviews revealed that during the afternoon hours, Staff #1 (S1) accessed the Memory Care Unit using a key from the opposite side of the secured egress door, which activated the alarm system. Staff #2 (S2) responded to assist S1 and disengaged the alarm system. Further interviews revealed that S1 and S2 had not been trained on the proper procedure to fully re-arm and engage the secured egress door system after it was disengaged. As a result, R1 exited the facility unnoticed later that evening. 911 and POA were notified of the incident. A search was initiated and approximately 30 minutes later R1 was found safely by police near St. Jhon’s Hospital. ED reported R1 did not sustain any injuries as a result of the elopement incident.

Continued on LIC 809-C

Desaree Perera
Valeria Conway
DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2026
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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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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Document Has Been Signed on 08/25/2026 02:54 PM - It Cannot Be Edited


Created By: Valeria Conway On 08/25/2026 at 12:07 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: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2026
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) Licensees that lock exterior doors… (2) The licensee shall ensure...the fire clearance...staff on all shifts have access to, and know how to use…
This requirement was not met as evidenced by:
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ASD will request ED to complete training with all MC staff, MedTechs and director on how to proper operate and re-arming of the secured egress door system. Training will be conducted by the Plant Operations Director.
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Based on an incident report and records review the ED did not comply with the regulation above as S1 and S2 were not properly trained to engage egrees door R1’s elopement.
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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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2026


LIC809 (FAS) - (06/04)
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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: ALMAVIA OF CAMARILLO
FACILITY NUMBER: 565800682
VISIT DATE: 08/25/2026
NARRATIVE
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Continued from LIC 809

During today's visit, LPA requested R1’s personal file. At 11:01 A.M., LPA discussed the incident with facility ED via telephone. R1’s Physician’s Report (LIC602A) indicates they are diagnosed with Alzheimer's Disease, have wandering behaviors and is not able to leave the facility unassisted. Service care plan report dated 07/02/2026 states under elopement risk "staff need to know where resident is at all times". After the incident, an in-service training was conducted on 07/28/2026, however S2 did not participate. Neither S1 nor S2 received disciplinary action following the incident. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)

Exit interview conducted, appeal rights discussed, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026
LIC809 (FAS) - (06/04)
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