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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 03:04:39 PM

Document Has Been Signed on 02/19/2025 03:04 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 - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Marjorie Manning - Health & Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit due to a deficiency observed during the investigation of a self-reported incident.

During today’s walkthrough, the LPA observed a video camera in the bedrooms of two (2) residents. Facility staff indicated the camera was placed by the resident’s family. Record review and interview conducted revealed that there is not an approved exception request on file with the Department allowing the use of cameras inside either resident’s room.

Citation issued. Exit interview. A copy of the report and appeal rights were provided.

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)
Page: 1 of 2
Document is an Amendment of Original Document on 04/14/2025 03:25 PM


Created By: Martha Arroyo On 02/19/2025 at 02:49 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
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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2025
Section Cited
HSC
1569

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Amended to reflect no citation issued.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2