<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850097
Report Date: 09/30/2024
Date Signed: 10/01/2024 08:10:33 AM

Document Has Been Signed on 10/01/2024 08:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CAMARILLO HAVENFACILITY NUMBER:
565850097
ADMINISTRATOR/
DIRECTOR:		CATABAY,ERIKA GRACEFACILITY TYPE:
740
ADDRESS:154 CAMINO CASTENADATELEPHONE:
(805) 512-0102
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Grace CatabayTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. LPA met with facility Administrator Erika Catabay and discussed the reason for today's visit. Entrance interview conducted.

At 10:30 A.M., LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire Extinguisher was observed to be fully charged and purchased on 08/29/2024. Hardwired combination smoke detectors and carbon monoxide detectors were tested at 12:52 P.M. and were functional at the time of the visit.

COMMON SPACES: In the common areas, including dining room and living room, walls and flooring were checked for cleanliness and good condition. At the time of the visit, furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was adequately screened. Auditorial signal was observed in each door around the facility. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during LPA observed a stopped keeping fire door open. This stopper prevents fire door from closing and violates fire codes.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:27 A.M. hot water temperature measured at 117.9 degrees Fahrenheit. Cleaning compounds were stored under the kitchen sink and separately from food supplies.



Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMARILLO HAVEN
FACILITY NUMBER: 565850097
VISIT DATE: 09/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 809

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use. Two (2) shared rooms and 2 private rooms. Also, LPA observed a staff room. Staff room was observed locked. There is a bathroom adjacent to the staff room designated for staff only inaccessible to residents.

BATHROOMS: The LPA observed 3 restrooms in the facility; 2 (two) are designated for resident use and one is a staff restroom. Resident restrooms are clean and sanitary with grab bars and non-skid surfaces. LPA observed that the toilet in the ladies’ bathroom was missing its lid. LPA observed men bathroom not to have a trash can with tight-fitting cover. Administrator replaced trash can immediately. Technical Advised was issued. Additionally, LPA observed both bathrooms without toilet paper. Administrator stated that dementia Resident #1 (R1), frequently enters both bathrooms and uses excessive amounts of toilet paper and paper towels, leading to unnecessary waste. As a result, toilet paper is not kept in the bathrooms to prevent this issue. Furthermore, LPA had a conversation with Administrator, during which LPA emphasized the importance of staff closely supervise R1 when in the bathroom to prevent waste or misuse of supplies. LPA explained that toilet paper and paper towels, shall be available for all residents and guests at all times to ensure proper care and accessibility. During LPA’s inspection, a sufficient supply of toilet paper was observed throughout the facility. Water temperatures were measured in all client bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.



OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for resident use. There are 2 side gate doors with self-latching mechanisms. Passageways were observed to be clear and free of hazards. There were no bodies of water noted. Outdoor shed was observed locked.

LAUNDRY ROOM/GARAGE: The washer and dryer were observed locked and inaccessible to residents. Cleaning supplies and disinfectants are kept in cabinets above the washer and dryer inaccessible to residents. Emergency food and Emergency water was observed in the locked garage.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMARILLO HAVEN
FACILITY NUMBER: 565850097
VISIT DATE: 09/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 809-C

RECORD REVIEW: Began at 11:45 A.M., staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were missing consent form (LIC 627C). LPA had a conversation with Administrator. Technical Advise was issued. Administrator will provide proof of complete form for each resident. All other required forms were complete and up to date. Four (4) staff files reviewed, all containing necessary documents.

MEDICATION REVIEW: Began at 2:30 P.M.; LPA reviewed medication log for all four (6) residents. Facility maintains a locked medication cart in the kitchen. Medications are labeled and checked for expiration dates. During medication audit, LPA discovered that Hospice Resident #2 (R2) was prescribed Zolpidem 5 MG once a day at bedtime on 09/25/2024. Staff member gave R2 medication on 09/25/2024, however from 9/26/2024 – 09/30/2025 prescribed medication was not administered. Also, Hospice Resident #3 (R3) had an order for Furosemide 20 MG. On the centrally stored medication and destruction record appears that medication was started on 09/09/2024. LPA checked bubble pack and from 09/09/2024 through 09/22/204 prescribed medication was given. After 09/22/2024 staff member stopped administering medication. Additionally, Hospice Resident #4 (R4), had a brand-new order for Lorazepam 0.5 MG to be started on October 1st. Audit of medication reflects that bubble pack was opened and 3 pills from container were missing. Administrator stated that Hospice services are confusing staff members by giving them verbally direction on how to administer prescribed medication. LPA explained Administrator, that any changes should be in writing not verbally. .

LPA obtained Client Roster, Staff Roster, and Liability insurance. Last emergency drill was conducted on 09/01/2024.

A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).
Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D):Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/01/2024 08:10 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/30/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMARILLO HAVEN
FACILITY NUMBER: 565850097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having fire door opened using a rubber stopper which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
1
2
3
4
Administrator had staff closing the door at the time of the visit. Administrator agrees to contact fire marshall to get a magnet to keep door open. Also, administrator will put a "Keep Closed At all Times" signed until magnet is in place.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above by not administering prescribed medication accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
1
2
3
4
Administrator will conduct an In-Service training with all staff and will clarify with hospice how medication should be administered.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/01/2024 08:10 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/30/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMARILLO HAVEN
FACILITY NUMBER: 565850097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a toilet without a lid. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
1
2
3
4
Administrator will purchase a new toilet lid and place it on the ladies' bathroom.
Type B
Section Cited
CCR
87307(a)(3)(D)
Personal Accommodations and Services
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above by not having paper towels and toilet paper in shared bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
1
2
3
4
Adminsitrator agreed to supply paper items in all bathrooms.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/01/2024 08:10 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/30/2024 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMARILLO HAVEN
FACILITY NUMBER: 565850097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited aboveby not having a acurate centrally stored medication log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Administrator will work with staff members and retrained them to accurately enter information on the centrally stored medication log
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 6 of 6