565801963-8-14-2020-29-AS-JAPL-BT5RA9-20200904125047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801963
Report Date: 08/14/2020
Date Signed: 08/14/2020 10:11:05 AM

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
06/26/2020 and conducted by Evaluator Kristin Heffernan

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200626101828

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: 92	DATE:	08/14/2020
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Vincent Gonzaga		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff not meeting resident's dietary needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Heffernan conducted a subsequent complaint investigation meeting to deliver the finding 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 meeting was conducted telephonically with Executive Director Vincent Gonzaga.

On 07/01/20, LPA Heffernan conducted an intial virtual visit via FaceTime. LPA toured the physical plant, including the kitchen, conducted interviews with residents and staff, and obtained facility records pertaining to Resident #1 (R1). Based on interviews and records review, R1 is being served specialized meals in accordance with R1's dietary restrictions. In addition, R1 has gained 8.4lbs from 02/04/20 to 06/16/20. Although R1 has a signed physician's order dated 05/01/19, indicating a restrictive diet, R1's most recent physician's report dated 01/28/20, notes no special diet needed.

Continued on LIC 9099-C...

Unsubstantiated

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: 08/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2020

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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Control Number 29-AS-20200626101828

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BROOKDALE CAMARILLO	FACILITY NUMBER: 565801963
	VISIT DATE: 08/14/2020

NARRATIVE

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During the virtual visit on 07/01/20, LPA observed R1 being served dinner. LPA confirmed with R1 that R1 would be able to eat the food, and that the items and quantity were sufficient. R1 indicated a past meeting had been held with the chef of the facility and an individualized meal plan was agreed upon for R1.

An additional interview on 08/10/20 with an outside-agency representative that has knowledge of the situation, also confirmed there is no suspected concern that the facility is not meeting R1's dietary needs.

Therefore based on the information received throughout the investigation, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of this report sent to Executive Director Vincent Gonzaga for signature.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kristin Heffernan	TELEPHONE: (747) 230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020

LIC9099 (FAS) - (06/04)

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