565801963-3-8-2022-29-AS-KHEN-CCD2WW-20220309164615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801963
Report Date: 03/07/2022
Date Signed: 03/08/2022 09:32:25 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
06/30/2020 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20200630130704

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:	0	CENSUS: 57	DATE:	03/07/2022
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Imelda Perez		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff threatened to unlawfully evict resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the allegation listed above. LPA met with Imelda Perez, Resident Care Director and explained the purpose for the visit is to conclude an investigation initiated by LPA Heffernan on 07/01/2020. Entrance interview conducted.

On 06/30/2020, the Department received a complaint alleging staff threatened to unlawfully evict resident. On 07/01/2020, beginning at 2:52pm, LPA Heffernan initiated the investigation both telephonically and virtually with the use of FaceTime to implement mitigation measures due to Coronavirus Disease 2019 (COVID-19). LPA interviewed Executive Director Vincent Gonzaga, staff and residents. LPA also obtained facility documentation, including a letter addressed to Resident #1 (R1) on 06/25/2020.

Continued on LIC - 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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-20200630130704

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: 03/07/2022

NARRATIVE

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Interviews revealed R1’s family often sneaks R1 out of the facility to go on unnecessary outings and R1 refuses to quarantine upon return to the facility. It shall be noted, at the time of this complaint, a visitation waiver was in place that restricted visitation per Community Care Licensing (CCL) Provider Information Notice (PIN) 20-04-CCLD dated 03/06/2020, in response to the Governor's Proclamation of a State of Emergency in response to the occurrence of COVID-19 in California. A letter was issued to R1 on 06/25/2020, which addressed R1’s non-compliance with the mandates set in place during that time period and requested R1 to limit non-medically necessary outings temporarily. In addition, the letter reminded R1 that the facility reserves the right to terminate R1’s Residency Agreement, which includes the option to terminate the agreement upon a thirty (30) days written notice for failing to comply with the general policies of the facility or engaging in conduct that poses a danger to themselves or others.

Based on the evidence obtained during the course of the investigation, it has been determined that the facility reminded R1 that their violations of state mandates and facility policies could potentially lead to a lawful eviction if R1 continued their pattern of behavior, but no formal eviction notice was served to the resident. Therefore, the allegation that staff threatened to unlawfully evict resident is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of this report was provided to Executive Director Vincent Gonzaga via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC9099 (FAS) - (06/04)

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