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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 06/14/2022
Date Signed: 06/15/2022 08:45:44 AM


Document Has Been Signed on 06/15/2022 08:45 AM - 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,
, CA



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:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Kailey VanderwallTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on 2 (two) self-reported incident reports. Upon arrival, LPA was informed Executive Director Martha Berard was unavailable. LPA met with Business Office Director Kailey Vanderwall and explained the reason for today's visit.

On 06/13/2022, the Woodland Hills Adult and Senior Care Regional Office (RO) received 2 (two) written incident reports via fax. One incident occurred on 06/05/2022 and involved Resident #1 (R1) eloping from the facility's secure Memory Care unit. The second incident also involved R1 eloping from the facility's Memory Care unit on 06/07/2022.

During today's visit, LPA toured the facility with Business Office Director at 11:40AM, during which all interior delayed egress doors were tested, interviewed staff at 12:08PM, 01:19PM and 02:40PM and tested the exterior delayed egress at 01:15PM. All interior delayed egress alarms were functional at the time of the visit. One exterior gate with delayed egress leading from the Memory Care patio to the Assisted Living courtyard was observed to be bolted shut at 01:14PM. Staff interview revealed that about a month ago, the delayed egress on that gate was not functioning properly and at that time, maintenance bolted the gate shut.

Record review revealed that R1 moved into the facility on 05/11/2022, has a history of wandering behavior, and is unable to leave the facility unassisted. Interview confirmed that R1 is known to be an elopement risk and when R1 is kept busy with activities, R1 is less likely to engage in wandering behavior. Staff interviewed stated they are unsure how R1 was able to exit the facility without an alarm sounding. Delayed egress is tested daily and staff reported it has been functional during all tests, as well as during today's visit. Staff stated it is possible R1 pushed the keypad code, disarming the system, and exited the door. Following the second elopement incident, the code was changed and R1 was given a Wanderguard bracelet.


Report Continued on LIC 809-C
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
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,
, CA
FACILITY NAME: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169
VISIT DATE: 06/14/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $500.00.

Exit interview conducted. Todays reports, appeal rights and civil penalties were reviewed with Business Office Director and emailed to the Administrator.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/15/2022 08:45 AM - 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,
, CA


FACILITY NAME: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/15/2022
Section Cited
CCR
87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...fire protection services, or the State Fire Marshal.
This requirement is not met as evidenced by:
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Upon Administrator's return to the facility, Administrator and LPA will discuss and agree upon a plan to ensure the safety of residents and facility compliance with the fire clearance. Interview indicated maintenance does not plan to fix the delayed egress until August 2022, which does not comply with the current POC requirements.
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Based on observation and interview, fire clearance incicates delayed egress is approved, however, an outdoor gate with delayed egress was non-functional and was subesquently bolted shut, which poses an immediate safety risk to residents in care.
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Type A
06/15/2022
Section Cited
CCR87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Facility staff stated that R1 was placed on frequent checks, they have spoken with R1's doctor, and R1's care plan will be updated. Memory Care Director will provide CCL with a copy of R1's reappraisal by 06/28/2022.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted twice, which poses an immediate health and safety risk to persons 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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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