565850142-7-12-2022-29-AS-KHEN-CGCVYA-20220715165048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:02:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2022 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220131173029

FACILITY NAME:	CAMARILLO SENIOR LIVING		FACILITY NUMBER:	565850142
ADMINISTRATOR:	GONZAGA, VINCENT		FACILITY TYPE:	741
ADDRESS:	6000 SANTA ROSA ROAD		TELEPHONE:	(805) 388-8086
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 53	DATE:	07/12/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Imelda Perez		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not change resident's bandages
Staff did not seek medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint inspection with the purpose of delivering findings for the allegations listed above. LPA met with Resident Care Director Imelda Perez at 01:55 PM. Entrance interview conducted.

During today’s visit, LPA and Resident Care Director toured the facility at 01:59PM. No health and safety hazards were identified during facility tour. Previously, on 02/08/2022, LPA Dulek conducted an initial complaint inspection during which, LPA toured the facility with Imelda Perez at 10:57 AM, interviewed staff at 11:13 AM, and conducted a file review at 11:50 AM. LPA received copies of documents pertinent to the investigation. Additionally, on the following dates, LPA Dulek interviewed staff and resident: 06/02/2022, and 06/09/2022. LPA also reviewed pertinent documents throughout the course of the investigation. The following was then determined:
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220131173029

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/12/2022

NARRATIVE

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Regarding the allegation: “Staff did not change resident's bandages:”

Record review indicated there is no doctor’s order for the resident to have bandages nor to have them changed. Staff interview revealed that R1 had come back from a medical visit with their legs wrapped and an order to keep the bandages on, however R1 removed the bandages themselves about an hour after returning to the facility. Resident Care Director has attempted to obtain an order for home health services to assist with R1’s bandages, however R1 refuses to see the primary care physician and therefore cannot obtain home health orders. While R1 has stated they need assistance with the bandages, there is no medical order to reflect this need. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation did occur, therefore the allegation “staff did not change resident’s bandages” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation: “Staff did not seek medical attention for resident:”

Staff interviews and resident interviews revealed that R1’s primary care physician released R1 from their care and subsequently R1 could not find an alternate primary care provider. R1 refused to see medical professionals that conduct visits on site at the facility. R1 chose an alternate provider, but the provider required R1 change specialists and pain medications, so R1 canceled services with the primary provider. R1’s family member does not help R1 find alternate medical care. Facility staff have attempted to assist R1 with scheduling appointments and locating adequate medical providers, however, R1 refused assistance and instead prefers to schedule themselves or to have their private caregiver make appointments. Staff interviews revealed that R1 chooses not to utilize facility transportation, but has a private caregiver take R1 to all medical appointments. Prior to the COVID-19 outbreak, R1 would leave the facility frequently and did receive medical attention regularly. Interview revealed that there was a time period when R1 did not have a private caregiver and facility staff indicated they assisted R1 in scheduling medical appointments and seeking medical attention as needed. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation did occur, therefore the allegation “Facility staff did not assist resident with medications as prescribed” is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of this report was provided via email to Resident Care Director and Executive Director.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC9099 (FAS) - (06/04)

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