565850108-6-1-2022-29-AS-KDUK-CEZ2KZ-20220601172847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 06/01/2022
Date Signed: 06/01/2022 05:29:23 PM

Document Has Been Signed on 06/01/2022 05:29 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 CARE		FACILITY NUMBER:	565850108
ADMINISTRATOR:	SPRING, BECKY		FACILITY TYPE:	740
ADDRESS:	50 OAK ST.		TELEPHONE:	(805) 586-4086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	36	CENSUS: 36	DATE:	06/01/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	05:02 PM
MET WITH:	Teresa Sacolles		TIME COMPLETED:	05:35 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit on 06/01/2022 at 5:02PM for the purpose of delivering the finding of an investigation conducted by the Department’s Investigation’s Branch (IB) Investigator Christine Ferris regarding a self-reported incident that occurred on 02/19/2022. LPA met with Facility Designee Teresa Sacolles and explained the reason for today’s visit. Entrance interview conducted.

On Sunday 02/20/2022 at 8:44AM, Administrator sent LPA Dulek a text message indicating there had been an incident involving Resident #1 (R1) and Resident #2 (R2) that occurred at the facility on 02/19/2022. Included in the text message was a link to media attention surrounding the incident and the statement that law enforcement had been involved. Due to the holiday weekend, LPA Dulek called Administrator on 02/22/2022 and requested additional documentation. The Woodland Hills Adult and Senior Care Regional Office (RO) received the incident report and supporting documentation on 02/22/2022. The incident report indicated that on 02/19/2022 at approximately 09:00AM, R1 was out on the smoking patio with other residents when R1 stabbed R2 with a knife, cutting R2’s ears, hands, and other unseen parts of the body. LPA Dulek conducted an in-person Case Management visit at the facility on 02/22/2022 at 11:12AM, during which LPA conducted an interview with facility designee at 11:15AM, toured the facility with designee at 11:45AM, and reviewed pertinent staff and resident records at 12:00PM. Investigator Ferris then conducted interviews with Law Enforcement, five (5) residents, four (4) facility staff, reviewed body worn camera video footage provided by Ventura County Sheriff’s Department, and reviewed R2’s medical records on the following dates: 02/24/2022, 02/28/2022, 03/09/2022, 03/17/2022, and 04/07/2022. The following was then determined:

Interview revealed that R2 had been out of the facility for some time and R2 returned to the facility on

Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

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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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
	VISIT DATE: 06/01/2022

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02/18/2022. On the morning of 02/19/2022, staff had entered R1’s room to clean and conduct a room search. R1 was laughing and joking with their roommate and the staff. R1 then went outside to smoke. While out on the smoking patio, R1 walked over to R2 and stabbed R2 several times before another resident realized what was happening and intervened. Staff inside the facility were made aware of the incident and responded promptly. Several residents witnessed the incident; all resident witnesses indicated the attack was unprovoked and no words were exchanged prior to the stabbing. Some residents interviewed were aware R1 did not like R2 and had witnessed verbal altercations between R1 and R2 previously. However, residents and staff interviewed stated they had never seen or heard of a physical altercation involving R1 prior to this incident.

Record review revealed that prior to residing in the facility, R1 had a history of violence for which R1 had been previously incarcerated. However, staff interviewed were unaware of R1’s history. Staff and residents interviewed indicated R1 had many friends at the facility, was “nice,” and was compliant with facility rules. Record review and interview revealed that house rules prohibit residents from possessing weapons. Facility staff conduct room searches twice daily during cleaning and if staff observe any prohibited items, they are confiscated at that time. It was revealed that R1 had purchased a folding knife from Resident #3 (R3) the day prior to the incident. Staff reported checking R1’s room regularly, including the morning of the incident and that R1 had never been found to have prohibited items in their room.

Based on the information and evidence obtained, there was insufficient evidence to support a lack of care and supervision at the facility at the time of this incident. Therefore, neglect/lack of supervision did not lead to R1 stabbing R2 with a knife. No citations issued at this time.

Exit interview was conducted and a copy of the report was issued via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC809 (FAS) - (06/04)

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