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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 09/22/2023
Date Signed: 09/22/2023 01:06:06 PM


Document Has Been Signed on 09/22/2023 01:06 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:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:FOERSCHNER, BRADLEEFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 82DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kailey VanderwallTIME COMPLETED:
01:10 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 a self-reported incident that occurred on 09/18/2023. LPA met with Business Office Director Kailey Vanderwall. Executive Director was not available during today's visit, however Ms. Vanderwall is authorized to sign all licensing reports. LPA explained the reason for today's visit.

On 09/19/2023 an Unusual Incident/Injury Report was received via e-fax at the Woodland Hills Regional Office. LPA reviewed the document, which indicates that Resident #1 (R1) left the community unsupervised and was found a block away. R1 resides in Assisted Living, however has a dementia diagnosis and is unable to leave the facility unassisted.

During today's visit, LPA along with Business Office Director toured the facility at 08:52AM, interviewed staff between 09:33AM to 10:30AM as well as at 12:31PM, and LPA obtained copies of pertinent documents. Additionally, LPA, along with Health Services Director and Business Office Director tested the Wanderguard alert beginning at 11:11AM, and LPA interviewed residents from 11:44AM to 12:13PM. During Wanderguard testing, it was observed that both the auditory alarm and electronic alert did not function on the Exit door next to Room 135.

LPA will return at a later date to continue the investigation into the incident that occurred, due to needing additional clarifying information from the Executive Director and to interview additional staff present at the time of the incident.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Business Office Director was informed that failure to correct the deficiency 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: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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Document Has Been Signed on 09/22/2023 01:06 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: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/23/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Business Office Director contacted Executive Director and Maintenance Director to inform them of the non-functioning alert. Facility Management is currently in the process of troubleshooting the issue. Maintenance is working with Phillips Lifeline remotely and is working to correct the error with the system.
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Based on observation, the Wanderguard system did not function properly, as auditory alarm did not sound nor did the electronic roam alert record when tested with a resident's Wanderguard bracelet on the door by room 135, which poses an immediate safety risk to residents in care.
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Management agrees to send proof of the door functioning properly with the Wanderguard system by POC due date. In the meantime, the facility has provided additional staff to watch the door and ensure resident safety.

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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: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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