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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801963
Report Date: 03/18/2021
Date Signed: 03/18/2021 02:16:08 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:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565801963
ADMINISTRATOR:GONZAGA, VINCENTFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA RDTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 83DATE:
03/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Jowell OvensonTIME COMPLETED:
12:02 PM
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Licensing Program Analyst (LPA) KaSandra Lopez initiated a tele-Case Management - Incident inspection to follow up on a self-reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s inspection was conducted telephonically at 11:29 AM with Health and Wellness Director Joel Ovenson. A face time virtual inspection was conducted at 11:54 AM.

On March 16, 2021, Community Care Licensing Division (CCLD) received a self reported unusual incident report (LIC 624) pertaining to Resident #1 (R1). On approximately March 13, 2021, R1 reported that their personal rights were violated while at the facility. Prior to today's inspection, the LPA corresponded telephonically with Mr. Ovenson on March 16, 2021 and March 17, 2021 regarding the allegation.

Further investigation is needed. Mr. Ovenson was advised that CCLD's Investigations Branch Investigator Jose Santana has been assigned to this investigation.

Telephonic exit interview was conducted. A copy of the report, along with a list of requested documents was emailed to Mr. Ovenson for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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