<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:32:22 PM


Document Has Been Signed on 06/20/2023 03:32 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, 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) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 50DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Gina GrundeisTIME COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA met with Executive Director (ED) Gena Grundeis and informed ED of the reason for the visit. Entrance interview conducted. ED indicated she has been working at the facility for approximately 2 and a half months, however the Regional Office did not receive notification in writing of a new ED within 30 days, per regulation. LPA discussed with ED paperwork required. All paperwork was provided during today's visit.

Beginning at 11:11AM, the LPA, along with ED 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. The following was observed:

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.

Common Areas: There were no obstructions and/or tripping hazards observed during facility tour. The facility maintains a comfortable temperature throughout the building. There are fire extinguishers throughout the facility, which were fully charged and last serviced 11/02/2022. Hardwired smoke detectors, fire doors and sprinkler system are inspected monthly, with the most recent inspection completed on 06/05/2023. Planned activities are offered. Activity schedule is posted throughout the facility. All activity rooms and common spaces appeared clean and in good repair. Cleaning supplies and disinfectants are stored locked per regulation. At 11:16AM, a storage closet containing used sharps was observed to be unlocked and accessible to residents in care. A working telephone is present. The LPA observed the required postings in the common area.

Resident Rooms: The facility consists of shared and private resident rooms, of which the LPA observed 10

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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
VISIT DATE: 06/20/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
resident rooms; 2 in Memory Care and 8 in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Resident Restrooms: Each resident room contains its own private restroom; full restrooms were observed in Assisted Living and half-bathrooms in Memory Care, with a common shower room. Resident restrooms observed contained sufficient grab bars and non-skid surfaces. Water temperatures were checked in all resident restrooms observed, and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit.

Outdoor Space: Multiple seating areas in both Assisted Living and Memory Care were observed with tables and chairs and shaded seating areas for resident use.

Resident Record Review: Began at 12:40PM, the LPA reviewed 5 (five) resident records for documents including, but not limited to: physician's report, TB test, needs and service appraisals, admission agreements, and personal rights. 5 (five) of 5 (five) resident records reviewed contained all appropriate documents.

Disaster Preparedness: LPA reviewed the facility's Disaster Preparedness binder. The facility's policies and procedures as it relates to Disaster Preparedness are adequate.

Kitchen: At 02:50PM, LPA Dulek observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply.

Infection Control: Not reviewed during today's visit

Medication Review: Not observed during today's visit

Staff File Review: Not observed during today's visit

interviews: During today's visit, LPA interviewed 3 (three) residents. Staff interviews will be conducted during Annual Continuation visit.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/20/2023 03:32 PM - It Cannot Be Edited

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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(b)(3)
87628 Diabetes
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(3) Ensuring that syringes and needles are disposed of as specified in Section 87303(f)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as a second floor storage closet, which contained an open container of used insulin injection prefilled pens, was observed to be unlocked which poses an immediate health and safety risk persons in care.
POC Due Date: 06/20/2023
Plan of Correction
1
2
3
4
Storage closet was locked during today's visit. POC cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/20/2023 03:32 PM - It Cannot Be Edited

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: 06/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(g)
87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, and record review, the licensee did not comply with the section cited above as Executive Director has been employed in her role for over two months and no documentation was received at the Regional Office informing of the change in Administrator, which poses a potential personal rights risk to persons in care.
POC Due Date: 06/20/2023
Plan of Correction
1
2
3
4
Executive Director provided documentation requested to change the Administrator to the LPA during today's visit. POC cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5