565801963-2-15-2023-29-AS-DPEA-CP5V5K-20230217150803

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801963
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:34:35 PM

Unsubstantiated

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
03/10/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210310085827

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
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:			TIME COMPLETED:	01:31 PM

ALLEGATION(S):

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Facility did not meet resident's hygiene needs.
Facility is not following resident's care plan.
Facility food is not adequate for resident.
Resident was made to wait excessive amount of time for assistance.

INVESTIGATION FINDINGS:

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On 02/15/2023, Licensing Program Analyst (LPA) KaSandra Lopez attempted to deliver the complaint findings regarding the above complaint allegations to 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 facility under this licensee closed effective 07/26/2021. A copy of this report will be mailed to the former licensee of the facility for signature.

On 03/10/2021, Community Care Licensing Division received a complaint regarding the above allegations. On 03/18/2021, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA Lopez conducted the initial complaint investigation telephonically at 11:29 AM with Health and Wellness Director Joel Ovenson. At 11:29 AM the LPA conducted a telephonic interview with Mr. Ovenson regarding the above allegations. At 11:54 AM a virtual inspection via face time was conducted. At 11:58 AM a face time interview was conducted with Staff #1 (S1). Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210310085827

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565801963
	VISIT DATE: 02/15/2023

NARRATIVE

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As of 07/26/2021, Camarillo Senior Living 565801963, closed and the facility location was re-licensed as Camarillo Senior Living 565850142. On 10/15/2021, the LPA conducted a Collateral Inspection at the facility currently licensed under Camarillo Senior Living 565850142. During this visit, the LPA met with Administrator Vince Gonzaga at the time and requested pertinent documents to the investigation. The LPA conducted a subsequent Collateral inspection at the facility on 02/10/2023. During this visit, the LPA conducted interviews with four residents and one staff member (Staff #2) between 12:49 PM and 1:30 PM.

The allegation of ‘Facility did not meet resident's hygiene needs’ alleges when Resident #1 (R1) was admitted to the hospital on 03/04/2021, they were unkempt, in soiled underwear and curled toenails. Interview with the Health and Wellness Director Jowell Ovenson at the time, revealed R1 was independent with bathing, groom, and toileting prior to hospitalization. R1’s most recent service plan dated 01/15/2021 reflects R1 was only receiving medication assistance. Interviews with S2 also revealed R1 was independent with ADLs and only received medication assistance. Based on the information obtained there is insufficient evidence to support ‘Facility did not meet resident’s hygiene needs’ occurred. Therefore, the allegation is deemed unsubstantiated at this time.

The allegation of 'Facility is not following resident’s care plan', alleges staff were not following R1’s care plan. A review of R1’s most recent care plan on 01/15/2021 revealed R1 did not need assistance with dressing, grooming, bathing, toileting, and was independent with mobility and only needed medication assistance. Interviews revealed R1 was receiving medication assistance. Based on the information obtained there is insufficient evidence to support the allegation of 'Facility is not following resident’s care' plan occurred. Therefore, the allegation is deemed unsubstantiated at this time.

The allegation of ‘Facility food is not adequate for resident’ alleges facility food was not good since the change of ownership. Interview with staff revealed the menu had changed around the time the complaint was filed, but they were not aware of any resident complaints regarding the food. Residents interviewed also revealed no issues regarding the food being served. Based on the information obtained there is insufficient evidence to support the allegation of Facility food is not adequate for resident occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Report continued on LIC 9099-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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210310085827

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: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565801963
	VISIT DATE: 02/15/2023

NARRATIVE

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The allegation of ‘Resident was made to wait excessive amount of time for assistance’ alleges R1 has waited sometimes up to two hours for staff to respond to their pendent call request. Pendent call records for R1 between 02/18/21 through and 03/03/2021 revealed response times ranged between five minutes and 23 minutes. On 03/04/2021, R1 used their pendent five times and response time were approximately, two minutes, 29 minutes, 14 minutes, six hours, and two hours. The last pendent call indicated “no signal” under activity. Staff interviewed indicated the 'no signal' was due to the pendent being out of range and stated the resident may have took the pendent with them when they were hospitalized. Staff also stated the long response time of six hours may have been due to staff not clearing the pendent when they responded to the call. LPA also reviewed pendent response times for two other residents during February and March 2021, and response times were between approximately one minute and 22 minutes. Interviews with residents revealed there are no issues or concerns regarding staff response time to pendent call requests. Based on the information obtained, there is insufficient evidence to support the allegation of ‘Resident was made to wait excessive amount of time for assistance’ occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Report and appeal rights were mailed to the address of the former 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

LIC9099 (FAS) - (06/04)

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