565850142-12-8-2022-29-AS-DPEA-CMCRGE-20221222120035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:11:07 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20220823153123

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:	ZIP CODE:	93012
CAPACITY:	140	CENSUS: 51	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	03:04 PM
MET WITH:	Okhawere (Misi) Ahanmisi		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff sexually abused resident
Failure to comply with reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Okhawere (Misi) Ahanmisi and discussed the reason for today’s visit. Entrance interview conducted.

Previously, LPA Angel Ascencio conducted an initial complaint inspection on 08/24/2022. During that visit, LPA Ascencio along with Administrator Vincent Gonzaga toured the facility at 09:55AM, gathered pertinent documents, and informed Mr. Gonzaga that Community Care Licensing Division (CCLD) Investigations Branch (IB) would be following up regarding the personal rights allegation. During the investigation, IB conducted an interview with Resident #1 (R1) on 09/01/2022, reviewed calls for service with Ventura County Sheriff’s Department, conducted interviews with R1’s private caregiver on 09/02/2022, facility staff on 09/02/2022, and reviewed a copy of R1’s lab report. Additionally, throughout the course of the investigation, LPA Dulek reviewed pertinent documents. The following was then determined:
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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-20220823153123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/08/2022

NARRATIVE

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Regarding the allegation “Staff sexually abused resident:”

The complaint alleges that while assisting R1 with daily care needs on the evening of 08/05/2022, Staff #1 (S1) inserted semen that had been obtained from Individual #1 (I1) into R1, who was residing in the facility’s Assisted Living unit. At that time, I1 was employed by the facility through an agency, which provides temporary caregivers during times the facility is experiencing staffing shortages. Review of R1’s facility documents revealed that R1 was incontinent and facility staff provided R1 with regular incontinence care as a part of R1’s Activities of Daily Living (ADLs). Interview revealed that S1 did provide ADL care for R1 on multiple occasions, as S1 was regularly employed by the facility as a caregiver in the Assisted Living unit. Interview and record review also revealed that R1 is non-ambulatory and is a 2-person physical assist for all transfers and incontinence care needs. Interview revealed that during the daytime hours Monday-Friday, R1 utilized a private caregiver. Facility staff was still assigned to provide R1’s ADL care, including showers, incontinence needs, dressing and grooming assistance. However, as R1 required 2-person transfer assistance, when R1’s private caregiver was present, only one facility staff would enter R1’s room to assist with incontinence care instead of the regular two facility staff. Interview revealed that 2 persons were always present in the room while incontinence care was being provided to R1.

Interview with S1 revealed that on an unknown date in early August while providing incontinence care, S1 noticed white discharge and had informed R1. R1 accused S1 of putting semen in R1 on 08/05/2022, rather than the Calmoseptine R1 was regularly prescribed. IB investigator confirmed that R1 did have a prescription for Calmoseptine. Additionally, record review revealed that on 08/06/2022, R1 was prescribed Monistat cream and Diflucan for a yeast infection. R1 refused the Diflucan order; subsequently on 08/07/2022, R1’s physician ordered Monistat 7 Simply Cure for a yeast infection diagnosis. R1 reported to R1’s family member that discharge found in R1’s incontinence brief was semen obtained from I1. R1’s family member then employed Technical Associates, Inc. to examine items collected in the investigation. A copy of the report was provided to CCLD and reviewed as part of the complaint investigation. Report indicated a sample was received on 08/17/2022 and all areas tested negative with this presumptive test for semen and no male DNA was detected in the sample. Later, on 08/20/2022, R1’s physician prescribed Vibramycin for Urinary Tract Infection (UTI). On 08/21/2022, facility staff noted R1 had yellowish to greenish discharge and informed R1’s family member and physician.

Interview with R1 revealed that R1 was unsure if S1 was present in their room on 08/05/2022 during the Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220823153123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/08/2022

NARRATIVE

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incident with I1 or if it was another staff who was present. Staff schedule review revealed that S1 worked the10:00PM to 06:00AM shift on 08/05/2022, but I1 was not on the schedule on that date. Both I1 and S1 were on the schedule for the 02:00PM to 10:00PM shift on 08/06/2022, however in an interview with IB, S1 denied ever providing incontinence care for R1 with I1 present. Additionally, R1 stated that I1 did not expose their private parts nor did I1 touch R1 inappropriately. R1 denied that I1 touched themselves inappropriately while around R1. R1 indicated they felt uncomfortable with the way I1 repositioned R1 because there was quite a bit of contact but, denied that I1 ever hurt them. R1 felt that I1’s motives were inappropriate but could not elaborate on how or if it was sexual. After the results from the lab came back negative for male DNA or semen, R1 stated it was a “false alarm” and apologized to S1 for the claim. Therefore, based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation that “staff sexually abused resident” is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Failure to comply with reporting requirements:”

The complaint further alleged that the facility failed to comply with reporting requirements. LPA Kelly Dulek reviewed communications with facility Health and Wellness Director Imelda Perez. LPA received an email from Ms. Perez at 06:24PM on 08/08/2022 indicating the private caregiver agency reported to the facility that R1 had made an allegation that I1 put sperm in R1. LPA called the facility the next morning and left a message for Ms. Perez. LPA also replied via email asking her to send the SOC 341 and corresponding incident report either via email or fax. An Unusual Incident/Injury Report and SOC 341 were received in the Woodland Hills Regional Office via e-fax on 08/09/2022 at 07:38PM and 07:36PM, respectively. Incident Report form indicated that on 08/07/2022 at around 09:40PM police officers were present in the facility to speak with R1. Staff spoke with R1, who indicated they had not called the police but had informed their private caregiver of the allegation. Police report reviewed indicated that at 03:55PM, APS called for a welfare check for R1, who had claimed a caregiver in the facility sexually assaulted them. Calls for service record indicates at 09:25PM on 08/07/2022, police officers arrived at the facility and were present in the facility until 10:08PM. No report was taken by the police officers present at the facility. Interview revealed that facility staff were unaware of the allegation prior to 08/07/2022 when the police were present in the facility. The Health and Wellness Director did send LPA an email within 24 hours of police presence in the facility. Fax confirmation to Long Term Care Ombudsman (LTCO) indicates the written report was sent to LTCO on 08/08//2022 at 09:50PM. Written report was sent to CCLD on 08/09/2022 at 09:36PM and law enforcement Report Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220823153123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/08/2022

NARRATIVE

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was already involved with the allegation when the facility was made aware. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “failure to comply with reporting requirements” is deemed UNSUBSTANTIATED at this time.

No citations were issued. Exit interview conducted. A copy of the 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: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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