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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 09/13/2024
Date Signed: 09/13/2024 02:56:57 PM


Document Has Been Signed on 09/13/2024 02:56 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:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR:GENA GRUNDEISFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 84DATE:
09/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Scott KeawekaneTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit due to a deficiency observed during the investigation of complaint #29-AS-20240429161933.

LPA met with back-up administrator Scott Keawekane who is the administrator of the skilled nursing facility attached to this property. Administrator Gena Grundes is out on a leave of absence. LPA met with administrator Keawekane and explained the reason for the visit.

During the Department’s investigation of complaint #29-AS-20240429161933, the following deficiency was observed:

The facility did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) to notify that on 04/23/2024 at approximately 5:52pm, Resident #1 (R1) was admitted to St. John’s Hospital for treatment for a severe cough. In addition, R1 was diagnosed with shortness of breath (SOB), bilateral lower extremity (BLE) edema, venous stasis, HTN, dementia, obesity, incontinence, weakness, and agitation. R1’s pressure injuries consisted of multiple decubitus ulcers. R1 had several wounds and skin breakdowns on the sacral area, abdominal fold, feet, and breasts. The facility also failed to notify R1's physician and the Department of R1's change of condition observed prior to 04/23/2024.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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 09/13/2024 02:56 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: CAMARILLO SENIOR LIVING
FACILITY NUMBER: 565850142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
HSC
87211(a)(1)(B)

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87211(a)(1)(B) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…..(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement is not met as evidenced by:
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The licensee will submit a plan describing how they will ensure reporting requirements are followed and have administrator and health director complete Reporting Requirement training. Submit proof to CCL by 9/20/2024.
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Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an incident report when R1 was hospitalized on 04/23/2024, which posed a potential health and safety risk to residents in 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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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