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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 07/08/2022
Date Signed: 07/08/2022 05:34:36 PM


Document Has Been Signed on 07/08/2022 05:34 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: 71DATE:
07/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:34 PM
MET WITH:Martha BerardTIME COMPLETED:
05:35 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 06/29/2022. LPA met with Executive Director (ED) Martha Berard and explained the reason for today's visit.

On 06/29/2022, LPA Dulek received a text message from Martha Berard indicating the Health Services Director (HSD) would be calling the LPA due to an incident that had occurred at the facility where Resident #1 (R1) eloped from the facility’s secure memory care unit. LPA received a phone call and voicemail from Health Services Director. Written report was faxed the same day, however, was not received in the Woodland Hills Regional Office (RO). A copy of the written report was obtained during today’s visit.

Previously, R1 had similar reported incidents on 06/05/2022 and 06/07/2022. At that time, the door code was changed, R1 was given a Wanderguard bracelet, all delayed egress exit points were tested for functionality, and a resident reassessment was completed. During today’s visit, LPA interviewed HSD at 04:10PM, LPA reviewed the staff schedule and compared to payroll records, and a tour of the secure memory care unit was conducted with ED Berard at 04:40PM. All delayed egress exit points were tested and functional during today’s visit. HSD indicated there was a care plan meeting with R1’s family today, R1’s physician adjusted R1’s medication and the memory care activity schedule was adjusted. HSD indicated all staff have reviewed the facility’s elopement procedure.

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 $250.00.

Exit interview conducted. Today’s reports, appeal rights and civil penalties were reviewed and provided via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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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Document Has Been Signed on 07/08/2022 05:34 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,
, CA


FACILITY NAME: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2022
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...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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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted, which poses an immediate health and safety risk to persons in care.
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date of training, roster of attendees, trainer, and topics covered by POC due date.

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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: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
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