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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850169
Report Date: 09/01/2022
Date Signed: 09/01/2022 06:37:25 PM

Substantiated


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
08/31/2022 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20220831113446
FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 80DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Bradlee Foershner/Kailey VanderwallTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is not serving good quality food to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 10:17AM and met with Executive Director Bradlee Foershner. Entrance interview conducted.

During today's visit, LPA toured the facility with Executive Director 11:05AM, interviewed staff at 10:36AM and between 11:35AM to 02:15PM, LPA reviewed and obtained copies of pertinent documents, and interviewed residents from 04:16PM to 04:57PM. The following was then determined:

During facility tour, beginning at 11:05AM, LPA Kelly Dulek and Executive Director Bradlee Foershner observed the kitchen, including all dry storage, walk-in refrigeration and frozen food storage. At 11:20AM, a container of Classic Horseradish was observed with an expiration date of 04/26/2022. At 11:20AM, a container
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
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 6
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
08/31/2022 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20220831113446

FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 80DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Bradlee Foershner/Kailey VanderwallTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility does not have enough food to serve residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 10:17AM and met with Executive Director Bradlee Foershner. Entrance interview conducted.

During today's visit, LPA toured the facility with Executive Director 11:05AM, interviewed staff at 10:36AM and between 11:35AM to 02:15PM, LPA reviewed and obtained copies of pertinent documents, and interviewed residents from 04:16PM-4:57PM. The following was then determined:

During facility tour, beginning at 11:05AM, LPA Kelly Dulek and Executive Director Bradlee Foershner observed the kitchen, including all dry storage, walk-in refrigeration and frozen food storage. LPA observed sufficient supply of perishable and non-perishable foods in all food groups, including emergency supply of
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220831113446
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: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169
VISIT DATE: 09/01/2022
NARRATIVE
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food and water. Interview with staff revealed that food ordering can be challenging at times, depending on items available through the facility's provider. Meals are prepared according to the printed menu and substitutions are documented as needed. Daily menus are printed and posted throughout the dining area, which reflect any substitutions that may have been made from the weekly printed menu provided to all residents. Interview revealed that a times the facility runs out of things such as black tea, coffee, ketchup, or syrup, but the menu items are available as scheduled. Based on interview and observation, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore the allegation that "Facility does not have enough food to serve residents" is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted with Business Office Director Kailey Vanderwall. A copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220831113446
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: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169
VISIT DATE: 09/01/2022
NARRATIVE
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 of Frank's RedHot Buffalo Sandwich Sauce was observed with an expiration date of 11/29/2021. At 11:22AM, LPA observed 4 containers of The Perfect Puree Blood Orange concentrate with a best by date of 06/18/2021 and at 11:23, LPA observed a large container in the freezer with a use by date of 08/15/2021. In addition, 11:15AM, it was observed and discussed there were numerous containers of Sysco Imperial Clam base and Arrezzio Anchovy Paste not labeled with an order date or an expiration date as well as cans of Mandarin Oranges with no date stamp or label. Interview revealed that staff have noticed expired foods in the kitchen as well and they are working on a better system for ordering foods and managing available stock. Based on interview and observation, the allegation that "Facility is not serving good quality food to residents" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted with Business Office Director Kailey Vanderwall. Today’s reports and appeal rights were reviewed and provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220831113446
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: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2022
Section Cited
CCR
87555(b)(8)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
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During today's visit, items identified were disposed of. Executive Director agreed to a full audit of all food items, including dry storage, refrigeration and freezer units to ensure all items are properly labeled and within appropriate expiration date range and will provide proof to CCLD by POC due date.
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Based on observation and interview, numerous food items were observed in the kitchen refrigerator and freezer to be expired and/or beyond the best by date, including Horseradish, Buffalo Sandwich Sauce and Blood Orange concentrate, 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6