565801963-7-26-2021-29-AS-AASO-C5ASFN-20210726135036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801963
Report Date: 07/22/2021
Date Signed: 07/26/2021 01:53:05 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 LIVING		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: 74	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Vincent Gonzaga		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 1:05 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Vincent Gonzaga and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with Administrator, Maintenance Director, Health and Wellness Director toured the physical plant areas inside and outside at 1:33 PM to ensure are there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 116 total bedrooms: 90 (ninety) assisted living resident rooms and 26 (twenty-six) are memory care resident rooms.

RESTROOMS: Public and resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallways. Fire extinguishers were observed to be serviced within the last year. Maintenance Director provided a copy of Inspection, Testing, and Maintenance Cover Sheet dated 1/7/2021, which indicated that the smoke detectors and pull stations were inspected and tested by Johnson Controls.

CONTINUED ON LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565801963
	VISIT DATE: 07/22/2021

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 1:25 PM. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility does not have a confirmed case of COVID-19 at this time. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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