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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802453
Report Date: 09/17/2021
Date Signed: 01/24/2022 11:33:15 AM

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:AT HOME CAMARILLOFACILITY NUMBER:
565802453
ADMINISTRATOR:COLON, MARGARITAFACILITY TYPE:
740
ADDRESS:417 GARDENIA AVETELEPHONE:
(805) 383-8893
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 4DATE:
09/17/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Margarita ColonTIME COMPLETED:
10:03 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced collateral visit at the facility today. This visit is regarding complaint number 29-AS-20210524120011 which is a complaint at another facility not related to At Home Camarillo.

LPA met with Administrator Margarita Colon upon arrival at 09:05 a.m. LPA explained the reason for the visit. At 09:15 a.m. LPA interviewed Resident #1 (R1). At 09:25 a.m. LPA reviewed R1's records at the facility and obtained copies of relevant documents.

There were no deficiencies observed during LPA's visit. An exit interview was conducted and a copy of this report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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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