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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850418
Report Date: 08/21/2024
Date Signed: 08/28/2024 10:21:30 AM

Substantiated


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
07/17/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240717140759
FACILITY NAME:AVANA HOME OF CAMARILLOFACILITY NUMBER:
565850418
ADMINISTRATOR:CARBAJAL, JESUSAFACILITY TYPE:
740
ADDRESS:574 MURRAY AVENUETELEPHONE:
(805) 612-4198
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 3DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Amelita Gagarin, Licensee/AdministratoTIME COMPLETED:
04:41 PM
ALLEGATION(S):
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Staff did not properly administer a resident's medications
Staff mishandled a resident's medications
Staff did not properly report an incident involving a resident
Resident was charged excessive fees
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with licensee. The reason for the visit was explained.

On 07/17/2024, Community Care Licensing Division received the above allegations. On 07/26/2024, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit and met with Licensee/Administrator Amelita Gagarin and spoouse. During the initial visit between the hours of 12:30pm-3pm, LPA conducted interview with Licensee/Administrator, staff, and resident. Also form 3pm-3:45m facility resident/staff records were reviewed.

Following is a summary of the allegations and investigation finding:
Regarding allegations “Staff did not properly administer a resident’s medications” and “Staff mishandled a resident's medications”: Information was received that the staff was not properly assisting and observing resident #1 taking medications. (Continue to LIC9099c).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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 7
Control Number 29-AS-20240717140759
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: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
VISIT DATE: 08/21/2024
NARRATIVE
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 It was also reported that medications were placed in a closed screw-top container, along with a closed bottle of water, and left for R1 to take unaided. On 7/26/2024, interviews conducted with Administrator. Administrator stated that the staff are to provide the medications to residents without the top on the container. Administrator and LPA observed the medications in the cabinet with the screw top containers. Administrator stated that the staff are to unscrew the container and provide the medication to the residents and make sure that they take the medication and not walk away. Administrator stated to LPA that she is not certain if the staff were providing the residents medication in this manner or not. Interview conducted with potential witnesses confirmed that staff #1 provided R1 with medications in a container with the top screwed on and walked away. Witness reported that medications were found on the floor and it was brought to the attention of staff. LPA made several attempts (08/9/24 at 6pm; 08/10/24 at 10am and on 08/11/24 at 2pm) to interview former staff (#1 and #2) however no return call was received. New staff hired was interviewed during the initial visit and they reported that they don’t handle the medications at this time. Administrator confirmed that she had multiple complaints regarding staff #1 and staff #2 therefore she terminated them.

Based on the above information gathered, there is sufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not properly administer a resident's medications” and “Staff mishandled a resident's medications” are deemed Substantiated this time.

Regarding Allegation “Staff did not properly report an incident involving a resident”: It was reported that R1 sustained a fall on 06/29/2024 which resulted in injuries and staff did not report the incident to the responsible person. Administrator reported that she was not aware that staff did not report the fall incident to R1’s responsible person on 06/29/2024. Interviews confirmed that R1’s fall was not reported to the responsible person.

Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Staff did not properly report an incident involving a resident” is deemed Substantiated at this time.

Regarding Allegation “Resident was charged excessive fees”: It was reported that R1 moved out of the facility on 07/06/2024. Interviews conducted with reporting party, Licensee/Administrator and resident records reviewed (Admission Agreement) revealed Licensee/Administrator did not issue appropriate refund to R1. (Continue to LIC9099c).
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20240717140759
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: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
VISIT DATE: 08/21/2024
NARRATIVE
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Further more, Licensee/Administrator charged additional fees for the remainder of the month totaling approximately $7000. R1’s admission agreement did not specify that "there is not refund due when 30day is not given by applicant/resident". Based on the above information gathered, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the allegation “Resident was charged excessive fees” is deemed Substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited.
Exit interview held. Appeal rights discussed and copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20240717140759
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: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2024
Section Cited
CCR
87465(a)4
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....(4)The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidence by:
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Licensee terminated staff and is currently handling the medication for resident(s).
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Based on observation, records review and interviews, licensee did not comply with above. Former staff did not assist residents with self-administering medications as needed and did not handle resident medication properly. This poses a potintal health and safety risk to residents in care.
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Type B
08/22/2024
Section Cited
CCR
87211(a)
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Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted... persons responsible for resident..
This requirement is not met as evidence by:
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Licensee terminated staff envolved. Licensee will submit self certification letter to state understanding reporting requirements; will follow requirement and also provide proof of in-service for staff.
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Basd on records review and interviews licensee did not comply with the above. Former staff and Licensee/Administrator did not report 1's injuries/incident to R1's responsible person.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20240717140759
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: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
CCR
87507(f)
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Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement is not met as evidence by:
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Licensee refunded monies owed to responsible person for resident #1. Submit confirmation to LPA by 08/22/2024.
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Based on interviews and records reviewed License did not comply with above section cited. Licensee did not adhere to refund policy and did not provide refund to R1 and issued excessive charges with no invoice or record.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
07/17/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240717140759

FACILITY NAME:AVANA HOME OF CAMARILLOFACILITY NUMBER:
565850418
ADMINISTRATOR:CARBAJAL, JESUSAFACILITY TYPE:
740
ADDRESS:574 MURRAY AVENUETELEPHONE:
(805) 612-4198
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:TIME COMPLETED:
04:41 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff behavior poses as a risk to resident in care
Staff are unable to communicate effectively
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver investigation finding. Upon arrival LPA met with . The reason for the visit was explained.

On 07/17/2024, Community Care Licensing Division received the above allegations. On 07/26/2024, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit and met with Licensee/Administrator Amelita Gagarin and spouse. During the initial visit between the hours of 12:30pm-3pm, LPA conducted interview with Licensee/Administrator, staff, and resident.
Also form 3pm-3:45m facility medication, resident, and staff records were reviewed.

Following is a summary of the allegations and investigation finding:
Regarding allegations “Staff behavior poses as a risk to resident in care and Staff are unable to communicate effectively”:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20240717140759
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: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
VISIT DATE: 08/21/2024
NARRATIVE
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It was reported that staff #1 and Staff #2 spoke condescending (like a child) to R1; staff lack understanding of the mental health care of the residents in care. In addition, it was reported that staff #1 acted inappropriately, and made crazy signs when talking about R1 and discuss residents in front of others. Administrator confirmed that she had multiple complaints regarding staff #1 and staff #2 therefore she terminated them. LPA made several attempts (08/9/24 at 6pm; 08/10/24 at 10am and on 08/11/24 at 2pm) to interview former staff (#1 and #2) however no return call was received. Resident and new hire was interviewed during the initial visit. Attempt was made to reach former residents and other potential witnesses; however no response was received.


Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations “Staff behavior poses as a risk to resident in care and Staff are unable to communicate effectively ” is deemed UNSUBSTANTAITED at this time.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7