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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:01:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20231122165440
FACILITY NAME:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR:GENA GRUNDEISFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 91DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Scott KeawekaneTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff does not respond to call button in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 09:55AM and was greeted by front desk staff. LPA met with pending Administrator Scott Keawekane who is also the Administrator of the skilled nursing facility attached to this property. Entrance interview conducted.

During today's visit, LPA toured the facility with pending Administrator at 11:35AM and LPA interviewed staff and residents between 10:35AM to 02:00PM. During an initial complaint visit conducted on 11/27/2023, LPA interviewed Executive Director at 01:08PM, toured the facility with Health and Wellness Director at 02:00PM, interviewed staff between 01:57PM and 03:00PM, and LPA reviewed and received copies of documents pertinent to the investigation. The following was then determined:

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20231122165440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMARILLO SENIOR LIVING
FACILITY NUMBER: 565850142
VISIT DATE: 11/05/2024
NARRATIVE
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LPA conducted both resident and staff interviews as well as reviewed call response logs for the time period surrounding the complaint. Staff interviewed indicated they try to respond as soon as possible when a resident pushes their button for assistance. The facility policy is no more than a 5 (five) to 10 (ten) minute call response. At the time of the complaint, staff reported there had been some functionality issues with the computer system the facility utilizes. This resulted in calls not showing up even when a resident pushed their button for assistance, so staff were unaware the resident pushed their call button. Residents interviewed indicated that it takes too long for staff to respond when the resident needs assistance up to 30 minutes. Staff interviewed confirmed that at the time of the complaint, residents were waiting too long. A review of Code Alert Alarm Response Report provided for 8 (eight) days around the time of the complaint revealed 49 (forty nine) calls that had a call response time of greater than 10 (ten) minutes, of which 12 (twelve) had a response time of 20-30 minutes, and 2 (two) that were over 30-minute response. Based on interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20231122165440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAMARILLO SENIOR LIVING
FACILITY NUMBER: 565850142
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed...To care, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Administrator will submit a plan to conduct testing on the call buttons to ensure they are functioning properly and conduct audits on response times.
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The licensee did not comply with the above cited section as interviews and record review of alert response times revealed many responses were not completed in a timely manner, which posed a potential health and safety risk to residents 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20231122165440

FACILITY NAME:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR:GENA GRUNDEISFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:140CENSUS: 91DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Scott KeawekaneTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff was tested positive for COVID
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 09:55AM and was greeted by front desk staff. LPA met with pending Administrator Scott Keawekane who is also the Administrator of the skilled nursing facility attached to this property. Entrance interview conducted.

During today's visit, LPA toured the facility with pending Administrator at 11:35AM and LPA interviewed staff and residents between 10:35AM to 02:00PM. During an initial complaint visit conducted on 11/29/2023, LPA toured the facility with Health and Wellness Director at 01:48PM, interviewed Health and Wellness Director at 02:08PM, and LPA reviewed and received copies of documents pertinent to the investigation. No immediate health and safety concerns were observed during facility tour. The following was then determined:

Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20231122165440
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CAMARILLO SENIOR LIVING
FACILITY NUMBER: 565850142
VISIT DATE: 11/05/2024
NARRATIVE
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It was alleged that staff were tested positive for COVID, yet continued to work at the facility wearing masks. During the initial visit, LPA did observe facility staff wearing surgical masks. LPA inquired as to why staff were wearing masks and facility management indicated it was a precaution due to flu season and the upcoming holidays. Interviews revealed that there was a staff on the skilled nursing side of the facility that had recently tested positive for COVID, but that this staff had not recently worked in the Assisted Living side of the facility. Management indicated there were no current active staff cases that had been reported. LPA confirmed with Ventura County Public Health that at the time of the complaint there was no active outbreak at this facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No citations issued related to the above allegation. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5