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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801948
Report Date: 06/24/2022
Date Signed: 06/24/2022 05:38:02 PM


Document Has Been Signed on 06/24/2022 05:38 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
CCLD Regional Office,
, CA



FACILITY NAME:NAVITA RESIDENCE EDGEMONT DRIVEFACILITY NUMBER:
565801948
ADMINISTRATOR:PRAVEEN SYAMALAFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRIVETELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
06/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Karthi VijayakumarTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management - deficiencies visit at this facility at 01:44PM in conjunction with a pre-licensing visit for a Change of Ownership application at the facility address. LPA met with Facility Representatives Karthiga Vijaykumar and Shamin Moor Mohamed. Entrance interview conducted.

During a facility tour, which began at 01:45PM, LPA observed Resident #1 (R1) residing in room #4, which is designated as non-ambulatory. R1's physician's report indicates they are bedridden. Fire clearance approval shows Room #7 as approved for bedridden residents and not Room #4. LPA observed a fire door as well as an exit door in Room #4. LPA contacted Fire Marshal in reference to this fire clearance for clarification.

During resident record review, which began at 02:13PM, LPA observed R1 who has a diagnosis of Dementia has a Physician's Report dated 03/02/2021 and a Needs and Service Appraisal dated 03/02/2021. Resident #2 (R2) who has a diagnosis of dementia and has had a recent change of condition has a Physician's Report dated 03/12/2021 and a Needs and Service Appraisal dated 03/29/2021.

During medication review, which began at 02:32PM, LPA observed R2's medications Cranberry, Finasteride, and PRN Tramadol have not been administered during the month of June 2022, are not present in the facility and do not have orders indicating the medications were discontinued. In addition, R2's Docusate Sodium is ordered for 250mg, however, the over the counter medication present in the facility was not properly labeled and is a 100mg dosage. R1's medication Clonazepam Centrally Stored Medication record indicates it was started on 06/15/2022 and is missing 1 additional dose of the medication than the number of days it has been administered.

Report continued on LIC 809-C
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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,
, CA
FACILITY NAME: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
VISIT DATE: 06/24/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Todays report and appeal rights were reviewed with Facility Designees and emailed to the Licensee's email address on file.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/24/2022 05:38 PM - 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,
, CA


FACILITY NAME: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited

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87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Based on record review and observation, the licensee did not comply with the
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 above section as three (3) of R2's were not present in the facility, R2's docusate sodium prescription is for 250mg but the pills present are 100mg each as well as R1's Clonazepam was missing one extra dose, which poses an immediate health and safety risk to residents in care.
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Type B
07/01/2022
Section Cited

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87465 Incidental Medical and Dental Care (h) (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the above section, as R2's aspirin, pain relief, and other over the counter medications were not properly labeled, which poses a potential safety risk to residents in care.
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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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/24/2022 05:38 PM - 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,
, CA


FACILITY NAME: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited

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87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual 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:
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Based on record review, the licensee did not comply with the above section as R1 and R2, both of whom have a diagnosis of dementia have Physican's Reports and Reassessments dated in March of 2021, which poses a potential health risk to residents in care.
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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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4