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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:27:15 PM


Document Has Been Signed on 06/02/2022 01:27 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:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR:GONZAGA, VINCENTFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 51DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Imelda PerezTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Health and Wellness Director Imelda Perez and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Food is prepared based on the menu and modified for individual residents' diets. The menu was posted and the facility offers alternate choices. Facility uses Cisco Foods for food deliveries, and delivery takes place three times a week. Snacks and beverages are available for residents at all times.

Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for independent living residents on the third floor, assisted living residents on all three floors and a separate secured unit on the first floor is designated for residents in the memory care unit. Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature throughout the building. There are fire extinguishers throughout the facility, which were fully charged and last serviced 03/03/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. Report Continued on LIC 809-C

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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: CAMARILLO SENIOR LIVING
FACILITY NUMBER: 565850142
VISIT DATE: 06/02/2022
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Common Restrooms: The LPA observed common restrooms. The LPA informed the Health and Wellness Director that signs promoting good hand hygiene should be placed in all common restrooms in the facility. However, all restrooms were fully stocked with soap and paper towels. During today’s visit, the LPA tested water temperature and the temperature measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.

Infection Control: During today’s visit, the LPA spoke with the Health and Wellness Director regarding the community's infection control practices. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation rooms if there is a confirmed case of COVID-19. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate.

No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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