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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802453
Report Date: 01/07/2025
Date Signed: 01/07/2025 03:13:40 PM

Document Has Been Signed on 01/07/2025 03:13 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AT HOME CAMARILLOFACILITY NUMBER:
565802453
ADMINISTRATOR/
DIRECTOR:		COLON, MARGARITAFACILITY TYPE:
740
ADDRESS:417 GARDENIA AVETELEPHONE:
(805) 383-8893
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Margarita ColonTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 09:40 A.M. LPA met with Licensee/Administrator, Margarita Colon. Entrance interview conducted.

Beginning at 10:05 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher is fully charged and purchased on 01/01/2025. Smoke detectors were tested at 1:52 P.M. and functional at the time of the visit. At 1:54 P.M. two (2) Carbon Monoxide detectors were tested. During the inspection it was observed that both detectors were missing batteries and were non-functional. Staff replaced batteries in both detectors, and they were retested. Following the replacement, both carbon monoxide detectors were confirmed to be functional. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies and sharps are located in a locked cabinet under the kitchen sink. LPA conducted a review of expiration dates on product labels. At 10:30 A.M. hot water temperature was tested and measured at 124.5 degrees Fahrenheit.

Continued on LIC 809-C
Desaree PereraTELEPHONE: (818) 596-4347
Valeria ConwayTELEPHONE: (818) 454-0485
DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/07/2025
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Continued from LIC 809

COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An adequately screened fireplace was noted in the living room. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 71 degrees. LPA observed a working phone available for residents use whenever needed. Facility provides sufficient space to accommodate indoor activities.

BATHROOMS: There are two (2) bathrooms for resident use. Both are designated for shared resident use. Restrooms were observed to be equipped with slip resistant surfaces and contain slip resistant mats. Grab bars were observed in the bathrooms. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. Residents have sufficient amounts of supplies for personal hygiene. At 10:48 A.M. hot water temperature was measured in one shared resident bathroom and measured at 118.2 degrees Fahrenheit.

BEDROOMS: There are five (5) total bedrooms in the facility; 1 (one) is designated as a shared room and 4 (four) are designated as private resident rooms. Occupied rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There is an additional bedroom for staff use.

GARAGE: Garage was observed locked and inaccessible to the residents in care. Garage contained laundry area, extra food, PPE and incontinence supplies, and emergency food and water.



Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/07/2025
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Continued from LIC 809-C

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. Facility has a side gate which was observed to be self-closing and self-latching with clear passageways for emergency exit use. LPA observed cameras throughout the outside of the property only. Facility provides sufficient space to accommodate outdoor activities. LPA observed two (2) sheds containing holiday decorations, extra PPE and incontinence supplies, mobility devices and gardening tools. The property has two (2) homes with different house numbers/address. The homes are separated by a fence.

RECORD REVIEW: Began at 11:00 A.M. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 2 (two) resident files observed were in compliance with regulation. LPA reviewed three (3) staff files including Administrator’s. LPA observed Staff #1 (S1) and Staff #2 (S2) were missing proof of valid 1st AID/CPR certification. During today’s visit S1 and S2 were able to renew 1st AID/CPR certificate online. All other personnel files were reviewed and found to be complete, with no missing documentation or deficiencies noted.

MEDICATION REVIEW: At 12:29 P.M. medications for 2 (two) residents were observed by the LPA. Medications are maintained locked in a hallway cabinet leading to the garage and they are inaccessible to residents. All medications observed were labeled and stored properly. However, discrepancies were identified in Resident’s 1 (R1) medication records during a medication count. The following was observed: Cyclobenzaprine 5 ML and Melatonin 3 MG were missing a dosage and Gabapentin 300 MG contained 3 extra capsules. Staff stated that R1 occasionally refuses to take medication. However, refusals were not documented in the centrally stored medication log nor the “end of date” staff notebook.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/07/2025
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Continued from LIC 809-C

LPA requested the following documents during today’s visit; Personnel Report (LIC 500), Handwritten Resident Roster, Liability Insurance. Emergency disaster drills are conducted quarterly, with the last drill conducted on 10/15/2024. Additionally, LPA observed emergency disaster plan to be complete and updated annually, as required.

INTERVIEWS: During today's visit, LPA interviewed 1 (one) staff and 1 (one) resident.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D) and civil penalty issued.



Exit interview conducted. Today's reports and appeal rights were discussed and copy was provided to Licensee.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria ConwayTELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2025 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AT HOME CAMARILLO
FACILITY NUMBER: 565802453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having inacurate count of medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2025
Plan of Correction
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Licensee agrees to conduct training with staff on how to dispense medication accurately and on how to maintain a updated refusal medication log.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree PereraTELEPHONE: (818) 596-4347
Valeria ConwayTELEPHONE: (818) 454-0485

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025

LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/07/2025 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: AT HOME CAMARILLO
FACILITY NUMBER: 565802453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having two carbon monoxide detectors with missing batteries which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Staff replaced batteries in both detectors, and they were retested. Following the replacement, both carbon monoxide detectors were confirmed to be functional. No proof of correction need it.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree PereraTELEPHONE: (818) 596-4347
Valeria ConwayTELEPHONE: (818) 454-0485

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025

LIC809 (FAS) - (06/04)
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