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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 02/22/2022
Date Signed: 02/22/2022 01:33:39 PM


Document Has Been Signed on 02/22/2022 01:33 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,
, CA



FACILITY NAME:OAK PLACE RESIDENTIAL CAREFACILITY NUMBER:
565850108
ADMINISTRATOR:SPRING, BECKYFACILITY TYPE:
740
ADDRESS:50 OAK ST.TELEPHONE:
(805) 586-4086
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:36CENSUS: 36DATE:
02/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Flordeliza HipolitoTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit at 11:12AM for the purpose of following up on a self-reported incident and to ensure resident health and safety. LPA arrived and met with facility designee Flordeliza "Baby" Hipolito. Entrance interview conducted.

On 02/20/2022, LPA received a text message from the Administrator Becky Spring indicating there had been an incident at the facility on 02/19/2022. Administrator indicated Ventura County Sheriff's Department had been notified of the incident that occurred between two residents and had taken a report on the date of the incident. On 02/22/2022, the Woodland Hills Adult and Senior Care Regional Office (RO) received an incident report stating that on 02/19/2022 at approximately 9:00 AM, Resident #1 (R1) and Resident #2 (R2) were outside in the smoking patio when R1 stabbed R2 with a knife.



During today's visit, LPA Dulek interviewed facility designee at 11:15AM, toured the facility with facility designee at 11:45AM, reviewed staff and resident records at 12:00PM, and received copies of pertinent documents. During file review, LPA discovered that staff #1 (S1) is not associated to the facility. File review and interview revealed that S1 began employment at the facility on 12/17/2021.

LPA determined that further investigation is needed regarding the Incident. LPA informed Facility Designee that Community Care Licensing Division's (CCLD) Investigation Branch (IB) Investigator and/or LPA will return to the facility at a later date to continue the investigation.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Today's reports, civil penalty, and appeal rights were reviewed and issued.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
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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Document Has Been Signed on 02/22/2022 01:33 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
CCLD Regional Office,
, CA


FACILITY NAME: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...(b) shall prior to working...in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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Based on file review and interview, Staff #1 has been employed at the facility since 12/17/2021 and does not have a criminal record clearance transfer to this facility, which poses an immediate safety hazard to resident is care.
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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.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2