565801963-7-22-2020-29-AS-AESA-BRYVLW-20200729163236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801963
Report Date: 07/22/2020
Date Signed: 07/22/2020 03:59:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2020 and conducted by Evaluator Kristin Heffernan

COMPLAINT CONTROL NUMBER: 29-AS-20200714153515

FACILITY NAME:	BROOKDALE CAMARILLO		FACILITY NUMBER:	565801963
ADMINISTRATOR:	GONZAGA, VINCENT		FACILITY TYPE:	741
ADDRESS:	6000 SANTA ROSA RD		TELEPHONE:	(805) 388-8086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 94	DATE:	07/22/2020
		UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Vincent Gonzaga		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff pulled resident's hair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Heffernan initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Vincent Gonzaga.

At 2:34pm, LPA Heffernan began an interview with Executive Director Vincent Gonzaga. Executive Director stated Resident #1 (R1), who is the focus of the complaint, resides on the skilled nursing side of the facility, rather than the assisted living side. Executive Director also explained Department of Public Health and law enforcement have already looked into the concerns regarding R1.

Based on R1 not residing on the assisted living side of the facility, LPA has deemed the allegation UNFOUNDED at this time. Exit interview conducted. A copy of this report was provided to Executive Director Vincent Gonzaga for signature and requested to be returned to the LPA on 07/22/20.

Unfounded

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kristin Heffernan	TELEPHONE: (747) 230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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