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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609903
Report Date: 09/14/2021
Date Signed: 09/14/2021 01:21:05 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:MARTHA BERARDFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:150CENSUS: 69DATE:
09/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Martha BerardTIME COMPLETED:
01:25 PM
NARRATIVE
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During a pre-licensing visit for a Change of Ownership application at the facility, Licensing Program Analyst (LPA) Kelly Dulek observed deficiencies under the current license.

During the facility tour, which took place with Administrator Martha Berard beginning at 8:50am, LPA took water temperatures in 7 randomly selected resident restrooms and in 1 common hallway restroom. At 9:37am in room 134, the hot water measured at 123.5 degrees F. At 9:43am in room 135, the hot water measured at 120.6 degrees F. At 9:57am in the second floor common restroom in Assisted Living, the hot water measured at 123.1 degrees F. At 9:40am in room 134, LPA observed water from the restroom faucet to be spraying over the restroom mirror, counter top, and floor. At 9:45am in room 135, LPA observed water from the restroom faucet to be spraying over the restroom mirror, counter top, and floor. Throughout the facility tour in both the Memory Care unit and the Assisted Living, LPA and Administrator observed fire extinguishers to have been purchased in 12/2019. While all fire extinguishers were observed to be in the green "fully charged" indicator, tags indicated annual service had not been performed.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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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: 567609903
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2021
Section Cited

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87303 Maintenance and Operation (2) Faucets used by residents...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water...not less than 105 degree F... and not more than 120 degree F...
This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure the hot water temperature was within the required range, measured at 123.5, 120.6, and 123.1 degrees F, which poses an immediate health risk to residents in care.
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Type B
09/21/2021
Section Cited

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80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not ensure the fire extinguishers were serviced annually, as they were last serviced 12/2019 and LPA observed the sinks in room 134 and 135 to spray a significant amount of water over the floor which poses a potential health and safety risk to clients in care.
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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: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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