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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850142
Report Date: 11/06/2025
Date Signed: 11/06/2025 11:58:12 AM

Unsubstantiated


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
11/02/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20251102182611
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: 114DATE:
11/06/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Scott KeawekaneTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff is mismanaging resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegation. During today’s visit, the LPA met with Wellness Nurse, Brenda Morales, and explained the reason for the visit. Executive Director (ED), Scott Keawekane arrived during the visit. Entrance interview.

During today's visit, between 09:40 a.m. and 11:30 a.m., the LPA conducted a plant tour, conducted interviews with three staff and one resident, conducted a medication review, a resident file review, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
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 2
Control Number 29-AS-20251102182611
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: 11/06/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff is mismanaging resident’s medication. It is the complainant’s concern that Resident #1 (R1) has been prescribed certain medications to help manage their pain; however, these medications are not being administered. Record review and interviews conducted revealed that R1’s current medication list includes the following pain medications: Norco 5-325 mg, 1 tablet by mouth every 6 hours as needed; Tylenol 8-Hour Extended Release 650 mg, 1 tablet by mouth every 8 hours as needed; and Tylenol 325 mg, 2 tablets by mouth every 4 hours as needed. According to the Medication Administration Record (MAR), the last time R1 received any PRNs was on 02/12/2025 for PRN Tylenol 650 mg. Staff interviews indicated that R1 frequently refuses medications, which has been ongoing since the beginning of the year. Staff also reported that they do not recall the last time R1 requested any PRN medication for pain. Further record review revealed that facility staff faxed R1’s Primary Care Physician (PCP) on 04/16/2025, to report R1’s repeated medication refusals and to inquire about possibly discontinuing the medications that R1 has been refusing. However, the facility has not received any orders or communication from the PCP regarding this matter. Staff stated that, in the meantime, they continue to document R1’s refusals on the MAR. Furthermore, during an interview, R1 stated that they have a low tolerance for pills and dislike taking medications. Based on the information obtained through record review and interviews, the Department has insufficient evidence to support the allegation of “staff is mismanaging resident’s medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC9099 (FAS) - (06/04)
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