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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801653
Report Date: 12/29/2020
Date Signed: 12/31/2020 05:46:40 PM

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:ROYAL GARDENS OF CAMARILLOFACILITY NUMBER:
565801653
ADMINISTRATOR:THOMAS AYERFACILITY TYPE:
740
ADDRESS:903 CARMEN DRIVETELEPHONE:
(805) 484-2777
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:130CENSUS: 113DATE:
12/29/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Dylan Hull, ConsultantTIME COMPLETED:
01:29 PM
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Licensing Program Analyst (LPA) Kelly Dulek initiated a case management - other visit to check on residents' health and well being. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Microsoft Teams with Dylan Hull, the facility consultant/designee. Also present virtually for today's visit were Licensing Program Manager (LPM) Kelly Burley and Ventura County Public Health Nurse.

During the virtual visit, Mr. Hull walked around the facility and showed all participants the facility common areas, including both Assisted Living and Memory Care, Dining Rooms, Activity Room, and the currently closed Beauty Salon and Movie Room. Staff observed were wearing proper PPE. Residents observed in the Memory Care unit were congregated in the common areas and not wearing masks. During the visit, mitigation measures were discussed, including cleaning and sanitation, donning and doffing of PPE, social distancing for facility residents, visitation policies, and isolation procedures. No immediate health and safety concerns were identified during the virtual visit.

A telephonic exit interview was conducted with Dylan Hull, and a hard copy of the report was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
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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