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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850418
Report Date: 12/29/2025
Date Signed: 12/29/2025 12:47:00 PM

Document Has Been Signed on 12/29/2025 12:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AVANA HOME OF CAMARILLOFACILITY NUMBER:
565850418
ADMINISTRATOR/
DIRECTOR:		CARBAJAL, JESUSAFACILITY TYPE:
740
ADDRESS:574 MURRAY AVENUETELEPHONE:
(805) 612-4198
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
12/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Jonie May Del RosarioTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at approximately 8:50 A.M. When the LPA arrived, there were two (2) staff members and five (5) residents present. The LPA was greeted by Caregiver, Ralph Renz Del Rosario and Jonie May Del Rosario. LPA informed the reason for the visit. Administrator was unavailable during today's visit, however caregivers are authorized to sign today’s report. Entrance Interview.

Beginning at 9:15 A.M., the LPA, along with caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed:

KITCHEN: Kitchen appliances appeared to be in operable condition. At 9:22 A.M. hot water measured at 118.3 degrees. Cleaning supplies and knives were stored in a locked cabinet under the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on some product labels.

BEDROOMS: There are five (5) bedrooms in total, of which two (2) are private rooms, two (2) are designated for shared resident use and one (1) is a staff room. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
VISIT DATE: 12/29/2025
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Continued form LIC 809

BATHROOMS: The facility has two (2) bathrooms, one (1) is a shared bathroom for residents, visitors and staff use and one (1) for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 9:33 A.M. and 9:38 A.M. hot water temperature was measured and measured within the required range.

LAUNDRY ROOM and GARAGE: LPA observed laundry room to be locked and inaccessible to residents in care. The garage is attached to the laundry room. Garage was observed to contain extra mobility aid supplies, decoration, cleaning supplies and storage. A low supply of Emergency water was observed in the garage. Technical Advisory (TA) issued. During today's visit staff purchased extra water supplies.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a temperature of 69 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Additionally, LPA observed three (3) hallway closets. One closet was unlocked and contained an ample supply of linen, towels, paper products and emergency food. The remaining two (2) closets were locked; one contained additional cleaning supplies, toiletries, and hygiene products, and the other housed medications for all residents, a complete first aid kit, and staff and resident files. Smoke and carbon monoxide detectors were tested at 9:45 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 02/05/2025.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has one side gate. LPA observed side gate to be self-latching and closing with clear passageways for emergency exit use.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AVANA HOME OF CAMARILLO
FACILITY NUMBER: 565850418
VISIT DATE: 12/29/2025
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Continued form LIC 809-C

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control and the emergency disaster plan are adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 10/01/2025.

During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A).



Due to time constraints, LPA will return at a later date to conduct medication audit and review staff and resident records.

No citations issued during today's visit, Exit interview conducted and copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4