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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 12/15/2021
Date Signed: 12/16/2021 08:48:29 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
FACILITY NAME:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR:GONZAGA, VINCENTFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 348-2214
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 66DATE:
12/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Imelda Perez, Resident Care DirectorTIME COMPLETED:
03:07 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Deficiencies visit to address concerns identified during a facility tour.

During today's visit, LPA Dulek conducted a facility tour with Resident Care Director at 10:50AM. At 10:54AM, in the Memory Care unit, LPA observed an unlocked supply closet, which contained a supply of Shampoo & Body Wash as well as No-Rinse Perineal Wash. At 10:55AM, also in the Memory Care unit, LPA observed the door to the laundry room propped open. Inside the unlocked and open laundry room, LPA observed laundry detergent and personal care items for residents, including Listerine, shampoo, body wash, and lotions.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports, and appeal rights were reviewed and emailed to the Administrator and Resident Care Director.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited

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(87705 Care of Persons with Dementia
f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidenced by:
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Based on observation, the Memory Care laundry room was unlocked with the door propped open and contained laundry detergent, Listerine, shampoos, lotions & the supply closet door was unlocked & contained shampoo, perineal wash, which poses an immediate health 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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