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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850169
Report Date: 03/18/2022
Date Signed: 03/21/2022 09:54:44 AM

Document Has Been Signed on 03/21/2022 09:54 AM - 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,
, CA
FACILITY NAME:OAKMONT OF CAMARILLOFACILITY NUMBER:
565850169
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:305 DAVENPORT STREETTELEPHONE:
(805) 738-3600
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 150CENSUS: 74DATE:
03/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Kailey VanderwallTIME COMPLETED:
06:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted a case management-deficiencies visit at the facility today. The LPA, along with Department of Justice (DOJ) Special Agents Alvin Hernandez and Julio Roman arrived at 01:35PM and met with Business Office Director Kailey Vanderwall. The LPA informed the Business Office Director of the reason for today's inspection. Entrance interview conducted.

During today's visit, LPA Dulek, along with Business Office Director and DOJ agents, conducted a facility tour at 1:40PM and gathered copies of documents pertinent to investigation. Additionally, LPA reviewed incident reports authored and submitted from 10/11/2021-present. Incident Reports informing CCL of COVID positive cases at the facility were received as follows: on 03/17/2022 indicating positive results on 02/24/2022, 02/20/2022 indicating positive results on 02/01/2022, 02/20/2022 indicating positive results on 01/31/2022, 02/01/2022 indicating positive results on 01/24/2022; and 01/14/2022 indicating positive results on 01/10/2022. LPA last spoke with Administrator Martha Berard on 03/07/2022 over the phone and reminded Administrator that all COVID positive reports need to be submitted with additional information within 24 hours of positive test results.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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Document Has Been Signed on 03/21/2022 09:54 AM - It Cannot Be Edited


Created By: Kelly Dulek On 03/18/2022 at 05:27 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
,
, CA

FACILITY NAME: OAKMONT OF CAMARILLO
FACILITY NUMBER: 565850169

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
03/18/2022
Section Cited
CCR
87211(a)(2)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(2) Occurrences, such as epidemic outbreaks...shall be reported within 24 hours...to the licensing agency and to the local health officer when appropriate.
This requirement is not met as evidenced by:
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Facility will immediately begin submitting incident reports in the timeframe required per section 87211. Facility will also conduct vendorized training on section 87211 with all staff and provide proof of training to include date, attendees, trainer, and content of training by 4/1/2022.
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Based on record review, the facility did not comply with the above cited section, since 5 incident reports indicating COVID positive cases have been received in the Regional Office past the 24 hour time frame, which poses an immediate 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.
SUPERVISOR'S NAME:
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


LIC809 (FAS) - (06/04)
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