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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:51:12 PM

Document Has Been Signed on 01/21/2025 03:51 PM - It Cannot Be Edited

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:CAMARILLO SENIOR LIVINGFACILITY NUMBER:
565850142
ADMINISTRATOR/
DIRECTOR:
GENA GRUNDEISFACILITY TYPE:
741
ADDRESS:6000 SANTA ROSA ROADTELEPHONE:
(805) 388-8086
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 140CENSUS: 88DATE:
01/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Scott KeawekaneTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Incident visit to follow up on an Incident Report (LIC 624) received by the department on 01/10/2025. Upon arrival, the LPA met with Executive Director (ED), Scott Keawekane and explained the reason for the visit. Entrance interview conducted.

The written report stated that on 01/10/2025 at approximately 1:05am, Staff #1 (S1) reported that at 12:50am while assisting Resident #1 (R1) with repositioning, R1 began to caress S1’s arm. Although S1 told R1 “not to do that” and attempted to back away from R1 but was unsuccessful. S1 pushed R1 back and left room. S1 reported incident to Staff #2 (S2) and Staff #3 (S3) after leaving R1’s room. Ventura County Sherriff’s department were also called and arrived at the facility shortly after.

During today’s visit, LPA Arroyo conducted a physical plant tour at 2:39pm, interviewed two staff and one resident between 2:50pm and 3:30pm, and obtained copies of pertinent documents. The LPA will return at a later date to complete the investigation if warranted.

No immediate or potential health and safety concerns noted at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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