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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850142
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:07:57 PM

Document Has Been Signed on 02/19/2025 03:07 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: 93DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Marjorie Manning - Health & Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Incident visit to follow up on a SOC 341 received by the department on 02/11/2025. Upon arrival, the LPA met with Health and Wellness Director, Marjorie Manning and explained the reason for the visit. Entrance interview conducted.

The report stated that Resident #1’s (R1’s) family reported to the facility that Staff #1 (S1) is stealing medication from R1’s bedroom.

During today’s visit, starting at 2:00pm., the LPA conducted a plant tour to ensure there are not health and safety hazards and observed eight (8) resident bedrooms. Additionally, between 2:15pm and 2:30pm, the LPA conducted interviews with four residents, conducted a staff interview at 12:25pm, and conducted a resident file review at approximately 12:45pm and obtained copies of pertinent documents relevant to the investigation.

The LPA will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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