565850169-9-14-2021-29-AS-KDUK-C6URVH-20210914132135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 09/14/2021
Date Signed: 09/14/2021 01:22:05 PM

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:	OAKMONT OF CAMARILLO		FACILITY NUMBER:	565850169
ADMINISTRATOR:	BERARD, MARTHA		FACILITY TYPE:	740
ADDRESS:	305 DAVENPORT STREET		TELEPHONE:	(805) 738-3600
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY:	150	CENSUS: 69	DATE:	09/14/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:36 AM
MET WITH:	Martha Berard		TIME COMPLETED:	01:25 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 at the facility at 8:36am for an announced pre-licensing inspection. This is a change of ownership application, but the facility name will remain the same. Upon arrival, the LPA met with Executive Director Martha Berard, who will remain as the Executive Director/Administrator for the new facility. The applicants successfully completed Component II on 7/29/2021 and Component III during today’s visit. A fire clearance was approved on 7/19/2021 and all rooms were cleared for non-ambulatory use. All rooms were cleared for bedridden use; however, this facility shall be limited to a maximum capacity of eight (8) bedridden residents. This facility has an approved Hospice Waiver for fifteen (15) residents. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was observed during today’s visit: COMMON AREAS: The physical plant tour took place at 8:50am. The facility is a two story building. Facility has 2 working elevators and 3 stairwells. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, medication room, bar/lounge area, library, activity rooms, formal sitting areas, beauty salon, fitness center, Wellness Center, office rooms, and common restrooms. On the second floor, there is a media room, laundry rooms, and common restrooms. The LPA observed fireplaces in the first floor dining area, library/reading room, the Bistro, and the formal sitting room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility uses a signal system, which is activated via pull cord in resident units and common areas. Alerts are sent to the front desk but also to pagers, which will be carried by staff. Residents will also have the option to use a pendant. There is a functioning telephone on the premises. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
	VISIT DATE: 09/14/2021

NARRATIVE

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Common Areas (Continued) Emergency exiting plans/sketch are posted throughout the facility. Other required postings were observed in the large activity room on the first floor.

There are fire extinguishers throughout the facility, which were observed to be fully charged, but last serviced 12/2019. The building received an inspection from the fire department on 7/19/2021 and smoke detectors, sprinkler system, and carbon monoxide detectors were observed to be in operating condition. Smoke detectors are hard-wired in the facility common areas. The LPA obtained appropriate documentation regarding the fire inspection for the hard file.

The LPA toured the outside area of the facility. There are two outdoor gated courtyards: one is designated for Memory Care residents and the other one is designated for Assisted Living residents. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Facility has a 20-seat passenger bus for transportation needs. There is parking available for resident use.

MEDICATION: There were two medication rooms on the first floor; one is designated for Assisted Living residents and the other for Memory Care residents. There were several complete first-aid kits and a surplus of medical supplies. The medication carts are equipped with a double locking system for narcotics.

KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries; food delivery takes place once a week for perishable and non-perishable menu items and every 3 days for produce. The facility has ample perishable and non-perishable foods to meet the minimum three-day and seven-day emergency supply of food and water, which was observed to be in good condition at the time of the visit.

RESIDENT ROOMS: Memory Care is located on the first floor and has 36 rooms. Out of the 36 rooms, 4 are identified for double occupancy. The Memory Care Unit has all studio apartments with no appliances. There is a separate dining space for Memory Care residents, and food will be prepared in the main kitchen and brought into the dining space for meals. All rooms in the Memory Care Unit are complete, with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs. There are motion sensors Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OAKMONT OF CAMARILLO	FACILITY NUMBER: 565850169
	VISIT DATE: 09/14/2021

NARRATIVE

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RESIDENT ROOMS (cont): installed in all Memory Care units. There are 54 Assisted Living units and can be found on the first and second floor of the building. Assisted Living units are either studio, one, or two bedroom units and rooms and are equipped with a refrigerator, sink, and microwave. All rooms in the Assisted Living Unit are complete, with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs.

During today's visit, water temperature was tested throughout the units and temperature ranged between 110 to 123 degrees Fahrenheit, which is not within the required range per regulation of 105 to 120 degrees Fahrenheit.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Hot water temperature in all rooms must be within the required range of 105 to 120 degrees Fahrenheit

2. Fire extinguishers last serviced in 12/2019 must be serviced or replaced

3.Faucets in room 134 and 135 must be replaced or repaired

This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

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