<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 07/11/2023
Date Signed: 07/18/2023 11:29:19 AM


Document Has Been Signed on 07/18/2023 11:29 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/18/2023 09:50 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

NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This report is an amendment of the original document in order to correct a misspelling of the Executive Director's name and correct an inaccuracy in the number of care staff files reviewed.

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct an annual continuation visit. The LPA met with Executive Director (ED) Gena Grundeis and informed ED of the reason for the visit. Entrance interview conducted.

Infection Control: LPA reviewed the facility's infection control policies and procedures with Executive Director and Health and Wellness Director. The facility's infection control policies are adequate.

Medication Review: Beginning at 01:47PM, the LPA along with Health and Wellness Director reviewed medications for 5 (five) residents. All 5 residents' medications reviewed were documented and stored in compliance with regulation.

Staff File Review: Beginning at 02:25PM, the LPA reviewed files for 5 (five) staff. The files were reviewed for documents including but not limited to: fingerprint background clearance, health screening, TB test, and training. Staff files for 2 (two) staff who assist with Activities of Daily Living do not have first aid training.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/18/2023 11:30 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/18/2023 09:53 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 565850142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 (two) of 2 (two) staff who assist residents with activities of daily living do not have record of first aid traning which poses a potential health and safety risk to persons in care.
POC Due Date: 07/25/2023
Plan of Correction
1
2
3
4
Executive Director agreed to have all staff complete first aid training and send proof of training to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2