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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:07:57 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
07/08/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210708125040
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: 53DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Imelda PerezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Facility did not address resident's medical condition
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 allegation 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 07/18/2021, LPA Dulek conducted an initial complaint inspection. During the initial inspection, LPA conducted an interview with Resident Care Director at 11:35AM, toured the facility at 11:55AM and observed a lunch seating, reviewed files and gathered pertinent documents at 12:10PM, and observed the kitchen and interviewed Dining Services Director at 12:35PM. Additionally, on the following dates, LPA Dulek interviewed staff and resident: 12/15/2021, 02/08/2022, 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 DulekTELEPHONE:
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)
Page: 1 of 5
Control Number 29-AS-20210708125040
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: “Facility did not address resident's medical condition:”

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. Staff and resident interviews later revealed that R1 attempted to change medical providers and subsequently 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, so R1 canceled services with the primary provider. R1’s family member does not help R1 find alternate care. Facility staff have attempted to assist R1 with scheduling appointments and locating adequate medical providers, however, R1 refused assistance. Record review indicated R1’s medical condition has not changed since R1 has resided at the facility. In fact, R1 was initially in recovery when R1 first moved into the facility and R1’s medical condition improved after initially moving in. 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 did not address resident’s medical condition” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of this report and appeal rights were provided via email to Resident Care Director and Executive Director.

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
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)
Page: 2 of 5
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
07/08/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210708125040

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: 53DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Imelda PerezTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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2
3
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5
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8
9
Facility not meeting resident's dietary needs
INVESTIGATION FINDINGS:
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5
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7
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9
10
11
12
13
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 Health Services Director toured the facility at 01:59PM. No health and safety hazards were identified during facility tour. Previously on 07/18/2021, LPA Dulek conducted an initial complaint inspection. During the initial inspection, LPA conducted an interview with Resident Care Director at 11:35AM, toured the facility at 11:55AM and observed a lunch seating, reviewed files and gathered pertinent documents at 12:10PM, and observed the kitchen and interviewed Dining Services Director at 12:35PM. Additionally, on the following dates, LPA Dulek interviewed staff and resident: 12/15/2021, 02/08/2022, 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
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
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)
Page: 3 of 5
Control Number 29-AS-20210708125040
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: “Facility not meeting resident's dietary needs:”

During the visit on 07/18/2021, LPA Dulek observed the dining room, kitchen, and interviewed Dining Services Director as well as Resident Care Director. LPA also reviewed R1’s care plan and facility file for any dietary needs. Interview revealed that if any resident has a special diet, there would be a diet slip for the orders, facility staff complete a communication paper. Interview revealed that there were no residents in Assisted Living with a special diet. LPA did not observe any indication in the kitchen of communication forms indicating special diets. However, record review indicated a physician’s order for a modified diet for R1, as well as one other resident. Additionally, R1’s personal service plan and assessment summary both also indicate R1 requires “texture modified foods” and R1 “chooses soft, low carbohydrate and low acid food from the menu.” During LPA’s in person visit, Dining Services Director located the diet orders for 3 residents and provided them to the LPA. Interview with R1 revealed that R1 purchases and prepares their own foods, as the facility has been unable to accommodate their dietary needs. Based on interview and record review, the allegation “facility did not meeting resident’s dietary needs” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
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)
Page: 4 of 5
Control Number 29-AS-20210708125040
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2022
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b) the following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
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Resident Care Director (RCD) agreed to review all residents’ files to ensure physician’s orders for modified diets are up to date and communicated to the dining room staff. RCD also agreed to provide proof to CCL that dining room staff are aware of physician’s ordered diets by providing a photo of the diet orders posted in the kitchen area.
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Based on observation, record review, and interview, the facility did not meet the above requirement as dining staff were unaware of physician’s orders for modified diets and R1 was not provided with their physician ordered diet, which poses a potential 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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5