565850142-6-2-2021-29-AS-KDUK-C3LSPT-20210602140340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:04:27 PM

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

FACILITY NAME:	CAMARILLO SENIOR LIVING		FACILITY NUMBER:	565850142
ADMINISTRATOR:	GONZEGA, VINCENT		FACILITY TYPE:	741
ADDRESS:	6000 SANTA ROSA ROAD		TELEPHONE:	(805) 348-2214
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 77	DATE:	06/02/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Vincent Gonzaga		TIME COMPLETED:	02:05 PM

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	Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing inspection for this proposed facility on 6/2/2021 at 10:45AM. This is a change of ownership application, but the facility name will remain the same. Vincent Gonzaga is the current administrator and was present at the time of the visit. A tour of the facility was initiated at 11:01AM with the Maintenance Director Jim Daniel and Resident Care Director Jowell Ovenson. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 114 total resident rooms – 90 in Assisted Living and 24 in Memory Care. All rooms have their own bathrooms. However, in Memory Care, the bathrooms contain a sink and toilet only and shared shower/bath is utilized. Each of the three floors has some form of common shared space, including but not limited to: activity room, dining room, and movie room. There is currently a total of 77 residents residing at the facility. Fire clearance was approved on 04/14/2021 for 130 non-ambulatory and 10 bedridden residents. Fire extinguishers were last serviced on 10/09/2020. Fire alarms/carbon monoxide detectors and fire doors were checked during the fire inspection on 4/14/2020. LPA observed all required postings on the wall in the main hallway and throughout the facility common areas. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Cleaning supplies are stored locked separate from food storage. Knives and sharp objects are stored per regulation. Medication: There is a locked medication room located on the second floor and in the memory care unit, as well as locked medication carts on each floor. LPA observed the third floor medication cart was locked and contained labeled medications for the residents. The facility utilizes an electronic MAR and communication Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMARILLO SENIOR LIVING	FACILITY NUMBER: 565850142
	VISIT DATE: 06/02/2021

NARRATIVE

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system. First aid supplies are available. Bedrooms: There are 114 total bedrooms in the facility. LPA observed a random sample of 10 resident rooms in both Assisted Living and Memory Care. All resident bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPA observed 10 resident bathrooms, which were clean, properly supplied and had functional fixtures. All observed bathrooms contained grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene. Water temperature was checked in all 10 resident rooms/bathrooms and measured between 108.8 and 112.2 degrees F. Common Areas: Each floor of the facility has at least one common area, including the dining room, activity room, and the movie room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a designated telephone available for resident use. At the time of the visit, the back elevator was not functioning properly, so it was out of use. There is a main elevator that was functional as well as available stairs. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. Memory Care unit patio contains a fenced outdoor area and delayed egress, which was functional at the time of the visit. There are no bodies of water on the premises. Supplies: LPA observed ample amounts of Emergency supplies, including water supply, emergency food, and generator. The facility also has ample PPE supply.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted with Administrator at 2:00pm. A copy of report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC809 (FAS) - (06/04)

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