565801963-2-15-2023-29-AS-KLOZ-CP434A-20230215165449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801963
Report Date: 02/15/2023
Date Signed: 02/15/2023 04:55:50 PM

Document Has Been Signed on 02/15/2023 04:55 PM - It Cannot Be Edited

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:	0	CENSUS: 0	DATE:	02/15/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:12 PM
MET WITH:			TIME COMPLETED:	03:13 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) KaSandra Lopez attempted to deliver the findings of a subsequent Case Management - Incident visit telephonically with Jeffrey Bradshaw, CEO of Management Company ACSR, LLC for Licensee S-H OPCO CAMARILLO LLC, but the LPA was only able to leave a message. The purpose is to conclude an investigation initiated by LPA Lopez during a virtual Case Management – Incident visit conducted on 03/18/2021. On 03/16/2021, Community Care Licensing Division (CCLD) received a self-reported unusual incident report (LIC 624) and Report of Suspected Elder Abuse (SOC341) pertaining to Resident #1 (R1). On approximately 03/13/2021, R1 reported that their personal rights were violated while at the facility. R1 alleged that they were sexually assaulted at the facility. On 03/16/2021 and 03/17/2021, Licensing Program Analyst (LPA) KaSandra Lopez corresponded telephonically with Joel Ovenson, facility Health and Wellness Director regarding the allegation. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Jose Santana. On 03/18/2021, from 11:29am to 12:02pm, LPA Lopez initiated a tele-Case Management - Incident inspection to follow up on the self-reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the inspection was conducted telephonically at 11:29am with Mr. Ovenson. A face time virtual inspection was conducted at 11:54am. The LPA requested documents pertinent to the investigation and advised Mr. Ovenson that CCLD's Investigations Branch Investigator Jose Santana was assigned to the investigation. Investigator Santana conducted interviews on 03/18/2021 with R1’s resident representative; and on 03/19/2021, with R1. In addition, the investigator reviewed facility file documents related to R1, Ventura County Sheriff’s Office calls for service summary, and St. John’s Pleasant Valley Hospital medical records. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: 02/15/2023

NARRATIVE

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R1 was admitted to the assisted living section of the facility from the skilled nursing section on 04/22/2020, with left hip pain, among other diagnoses. It was noted R1 had a periprosthetic fracture around the internal prosthetic left hip joint. The Physician Report, dated 04/17/2020, listed R1’s primary diagnosis as displaced oblique fracture of left femur shaft, with secondary diagnoses of sick sinus syndrome, type 2 diabetes, and anemia.

According to the Unusual Incident Report dated 03/16/2021, the Wellness nurse found R1 unresponsive during round checks on 03/13/2021. R1 was sitting in their recliner chair and did not respond to verbal or tactile cues. The nurse called 911, and paramedics transported R1 to St. John’s Pleasant Valley Hospital. When R1’s resident representative called to check on R1 at the hospital, R1 alleged that they had been sexually assaulted the night before at the facility.

The medical records reviewed revealed that R1 arrived at St. John’s Pleasant Valley Hospital on 03/13/2021 at 10:16am via ambulance due to an admitting diagnosis of altered mental status (due to dehydration). Approximately one hour before arriving at the Emergency Room, at around 9:45am, R1 was noted as being in an altered/confused state. The hospital tests were negative for neurological issues (i.e., stroke) after a CT scan of the brain. R1 became more responsive after receiving fluids. The CT scan of R1’s abdomen and pelvis taken on 03/13/2021 at 10:13pm, found no evidence of acute inflammatory process within the abdomen or pelvis.

R1 was admitted for observation throughout the night on 03/13/2021 and was discharged on 03/14/2021 at 2:17pm with diagnoses of metabolic encephalopathy and dehydration, after having no overnight changes and no new neurological deficits.

Report continued on LIC 809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: 02/15/2023

NARRATIVE

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During the interview process R1 confirmed to investigator Santana that they were recently hospitalized. R1 did not have any memory of what transpired, and the last memory before waking up in the hospital was falling asleep on R1’s recliner chair, where they usually sleep. R1 believed they must have become unresponsive overnight because the staff found R1 in the morning. R1 was told that doctors did all kinds of testing and could not find out what happened, that there was no definite conclusion. After R1 returned to the facility, R1 was notified that R1 made an allegation of sexual assault, but does not remember being assaulted, nor does R1 remember making the allegation. R1 stated they have no idea why they would make the allegation except to say that maybe it was possible R1 saw something on television that “made me think of something like this”. R1 mentioned several times that they likely made the allegation as a result of something they watched on television. R1 denied feeling uncomfortable around any staff member. When asked if R1 felt safe in the facility, R1 replied “yes”.

Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the above allegation. R1 had no recollection of being sexually assaulted or making the allegation. The hospital x-rays were normal.

No deficiencies were observed during the investigation at this time. A copy of the report was mailed to the licensee for signature.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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