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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 04/06/2022
Date Signed: 04/06/2022 05:28:07 PM


Document Has Been Signed on 04/06/2022 05:28 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,
, 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: 77DATE:
04/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Martha BerardTIME COMPLETED:
03:03 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident report verbally reported to LPA on 04/01/2022, and written report on 04/05/2022. LPA met with Administrator Martha Berard and explained the reason for today's visit. Entrance interview conducted.

On 04/01/2022 at 3:52PM, LPA received a phone call from Administrator Martha Berard reporting a possible incident involving two facility residents that occurred on 03/31/2022 around 7:47PM. LPA requested pertinent documents be sent to the LPA, along with a written incident report. The Woodland Hills Adult and Senior Care Regional Office (RO) received the written incident report and supporting documentation via fax on 04/05/2022.

During today's visit, LPA toured the facility with Business Office Director Kailey Vanderwall at 1:35PM, and interviewed residents from 1:49PM - 2:57PM. No immediate health and safety concerns were observed during today's visit.

LPA has determined further investigation is needed. The LPA will return at a later date to continue the investigation.

Due to technical difficulties, exit interview was conducted via telephone with Administrator Martha Berard at 5:24PM. Report was issued via email for signature.

SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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