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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609903
Report Date: 09/01/2020
Date Signed: 09/01/2020 04:53:28 PM

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:
567609903
ADMINISTRATOR:SUSAN RALPHSFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 74DATE:
09/01/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:27 PM
MET WITH:Susan RalphsTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced tele-inspection due to a self reported incident. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Case Management Tele-inspection was conducted telephonically with Health Service Director Susan Ralphs.

The reason for today's inspection was to follow up on the self reported incident and subsequent death reporting of Resident #1 (R1). During today's inspection, the LPA conducted a telephonic interview beginning at 3:27 PM with Staff #1 (S1). At 3:53 PM, the LPA also conducted a telephonic interview with Staff #2 (S2). At 4:07 PM a virtual inspection was conducted of the dining room area and the common entry way area. Further investigation is needed. The LPA requested pertinent records to be emailed to the LPA.

A telephonic exit interview was conducted with Susan Ralphs, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kasandra LopezTELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020
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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