Avana Home of Camarillo

Type of visit: Required - 1 Year

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 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 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.the state’s words, verbatim · CDSS document, Dec 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at approximately 9:00 A.M. When the LPA arrived, there was three (2) staff members and three (3) residents present. The LPA was greeted by Caregiver, Jonie Nay Del Rosario. LPA informed the reason for the visit. Caregiver contacted the Administrator by phone, Amelita Gagarin. At 9:20 A.M., Administrator and back up Administrator Jovelito Gagarin, arrived at the facility. At 10:14 A.M. Administrator received a phone call and had to exit annual visit. Back-up administrator is authorized to sign today’s report. Entrance Interview. Beginning at 9:43 A.M., the LPA, along with Administrator and back-up Administrator 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 9:45 A.M. hot water measured at 111.8 degrees. Cleaning supplies were stored in a locked cabinet under the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food. At 9:57 A.M., LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Back-up Administrator discarded all three (3) items during today’s visit. Technical Advice Issued. Continued on LIC 809-C Continued from LIC 809 Between 9:47 A.M. and 9:52 A.M. LPA asked Administrator to show where knives are stored. Back-up Administrator opened the dishwasher and slid open an interior drawer containing all sharps. Back-up Administrator stated that residents don’t use the dishwasher and are unaware of where knives are stored. During a check of the kitchen drawers, the LPA observed an approximately 5-inch kitchen knife in the utensil’s drawer. LPA explained that per regulation knives and sharps shall be locked and inaccessible to residents in care. LPA requested Administrator and back-up Administrator to secure all sharps immediately. Going forward, staff will store knives and sharps in the locked hallway cabinet where medications and First aid kit are kept. BEDROOMS: There are 5 (five) bedrooms total, of which 2 (two) are private rooms, 2 (two) are designated for shared resident use and 1 (one) is a staff room. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. BATHROOMS: The facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:08 A.M. and 11:18 A.M. hot water temperature was measured and measured within the required range. LAUNDRY ROOM: LPA observed laundry room to be locked. Cleaning supplies and hygiene products were observed to be locked in a hallway cabinet and properly stored at the time of the visit. GARAGE: The garage is attached to the house. Garage was observed to contained extra mobility aid supplies, decoration, cleaning supplies and storage. Emergency water was observed in the garage. 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. However, Long-Term Care Ombudsman poster was covered by Community Licensing forms. The LPA requested that the Administrator remove these forms and ensure that the poster remains free of obstructions at all times. Technical Advice issued. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable 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. Continued on LIC 809-C Continued from LIC 809-C There is also an ample supply of linen, towels and paper products. LPA observed night-lights were present in the hallways. On the hallway a locked cabinet was observed, there facility keeps staff and resident files and medication. Smoke and carbon monoxide detector were tested at 11:03 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 09/20/2023. During today’s visit back-up administrator got the kitchen’s fire extinguisher serviced by Service-Pro Fire Protection. New annual service date reads 11/06/2024. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident 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. RECORD REVIEW: Between 11:19 A.M. and 12:27 P.M., Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) resident records reviewed were complete and contained all required documents. Five (5) staff files including Administrators were reviewed. LPA observed that Staff #1 (S1) and Staff #2 (S2) were hired in 08/2024 but are not CPR training was not complete. Additionally, LPA observed missing ID form (LIC 501), Job application, Health Screening form (LIC 503) and Criminal Record Form (LIC 508) for S1. During today's visit S1 completed LIC 508, LIC 501. MEDICATION REVIEW: At 12:42 P.M. LPA started medication review. Medications for three (3) residents were observed. Medications are centrally stored and locked in a hallway cabinet. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. residents' medications are maintained and administered in compliance with regulation. Continued on LIC 809-C Continued LIC 809-C During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A). A copy of the facility's liability insurance. Emergency disaster drills are conducted quarterly, with the last drill documented on 10/05/2024. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

Allegation investigated: 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

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 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). 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. 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.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 29-AS-20240717140759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)4 · Plan of correction due date: Aug 21, 2024

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: 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.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Licensee terminated staff and is currently handling the medication for resident(s).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Aug 22, 2024

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: 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.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Aug 22, 2024

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: 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.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Licensee refunded monies owed to responsible person for resident #1. Submit confirmation to LPA by 08/22/2024.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 10:07AM. LPA met with applicant representatives Jesusa Carbajal, Amelita Gagarin, and Jovilito Gargarin. The applicant has obtained fire clearance for 4 (four) non-ambulatory, 1 (one) ambulatory, and 1 (one) bedridden with a total capacity of 6 (six) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for 3 (three) residents. Applicant completed component II interview on 11/14/2023. During today's visit, Applicant representatives completed component III with the LPA. Beginning at 10:19AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 10:49AM and function properly at this time. Fire extinguisher was observed to be fully charged and serviced 09/29/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A properly screened fireplace was observed in the living room. A working telephone is present. All required postings were observed in the common area. The facility contains a staff room/office and laundry room. All chemicals and cleaning supplies were observed in a locked hallway cabinet. A locked medication cabinet was observed, as well as a locked cabinet designated for record storage. First aid kit was observed to be complete. Garage was observed to be locked and inaccessible to future residents and contained emergency water and supplies. The proposed facility has 4 (four) bedrooms total, of which 2 (two) are private rooms and 2 (two) are designated for shared resident use. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. LPA observed night-lights were present in the hallways. Hot water Report Continued on LIC 809-C initially measured at 135.1 degrees Fahrenheit. Water temperature was adjusted during the visit, LPA retested the water, and it measured within the required range prior to the end of the visit. The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives and cleaning supplies were stored in a locked cabinet under the kitchen sink. Building and grounds were observed. Patio area contains a seating area for future resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of any hazards. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 29, 2023

Type of visit: Office

COMP II by CAB successfully completed Capacity: 6 Census (if any clients in care): Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Nov 14, 2023