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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609903
Report Date: 07/19/2021
Date Signed: 07/19/2021 08:22:17 AM

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:LEATRICE BOGOYEVACFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 77DATE:
07/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:05 AM
MET WITH:Brenda ReyesTIME COMPLETED:
08:25 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced case management inspection due to a self reported incident. LPA met with Memory Care Medication Technician Myra Nava and explained the reason for the visit. Memory Care Director Brenda Reyes arrived at 8:10AM.

The reason for today's inspection was to follow up on the self reported incident involving Resident #1 (R1). During today's inspection, the LPA conducted staff and resident interviews at 7:15AM, 7:26AM, 7:51AM, and 8:14AM. LPA toured the Memory Care unit at 7:15AM and the Assisted Living unit at 7:50AM. LPA requested pertinent documents be emailed or faxed to the LPA. At this time further investigation is needed.

A telephonic exit interview was conducted with Brenda Reyes, and a hard copy was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
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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