<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850778
Report Date: 09/29/2026
Date Signed: 09/29/2026 04:28:23 PM

Document Has Been Signed on 09/29/2026 04:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PARK PLACE CAMARILLOFACILITY NUMBER:
565850778
ADMINISTRATOR/
DIRECTOR:		CHARETTE, HEIDIFACILITY TYPE:
740
ADDRESS:903 Carmen DRTELEPHONE:
(805) 586-4191
CITY:CamarilloSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 53DATE:
09/29/2026
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Gloria Morales, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a post-licensing visit. Upon arrival, the LPA met with the receptionist then met with Executive Director (ED) Gloria Morales shortly after. The reason for the visit was explained. Entrance interview conducted.

The LPA, along with the ED, conducted a physical plant tour starting at 11:14AM. The physical plant areas were inspected inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: The facility consists of 107 total bedrooms, of which LPA observed ten (10) random resident bedrooms; three (3) in the Meadows (Memory Care) and seven (7) in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. One (1) resident room (Resident #1's room) observed in the Memory Care unit is a bedridden room and the magnet latching mechanism was observed broken off from the wall. ED indicated this was broken over the weekend and is scheduled to be repaired today once parts are obtained.

RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and slip-resistant surfaces. The LPA observed that the restroom belonging to Resident #2 (R2) had broken and possibly water damaged tiles surrounding the toilet area. Water temperature was tested in seven (7) resident restrooms and measured between 107.1 and 135.5 degrees Fahrenheit, with six (6) of the seven (7) rooms measuring above the required range.

Report Continued on LIC 809-C

Kristin Heffernan
Kelly Dulek
DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2026
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 8
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)
Page: 2 of 8
Document Has Been Signed on 09/29/2026 04:28 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/29/2026 at 03:20 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE CAMARILLO
FACILITY NUMBER: 565850778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 6 of 7 resident rooms' water temperature measured between 130.1 and 135.5 degrees Fahrenheit which poses an immediate safety risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
1
2
3
4
During the visit, Maintenance Director turned the temperature down on the two boilers. Executive Director agreed to measure water temperature in various rooms at random times each day for 7 days and all temperature readings will be recorded on a water temperature log. Water temperature log will be submitted to CCL by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/29/2026 04:28 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/29/2026 at 03:20 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE CAMARILLO
FACILITY NUMBER: 565850778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as during the facility tour, the trash enclosure in the memory care yard was observed to be broken and overflowing with trash, the bedridden room door magnet in R1's room was observed to be broken off the wall, flooring around the toilet in R2's room was broken, and janitor closet doorknob was broken, which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 10/13/2026
Plan of Correction
1
2
3
4
ED agreed to ensure all broken items are repaired as soon as possible and proof will be sent to CCL upon completion.
Type B
Section Cited
CCR
87211(g)
87211(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as the designated Administrator has not been prsent in the facility in approximately 2 months, when the Executive Director assumed the role, however no notification was sent to CCL, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/13/2026
Plan of Correction
1
2
3
4
ED agreed to contact the management company and ensure all documentation indicating the change in Administrator is sent to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 09/29/2026 04:28 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/29/2026 at 03:20 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARK PLACE CAMARILLO
FACILITY NUMBER: 565850778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above, as 5 of 5 resident files reviewed did not have a current reappraisal signed or reviewed with the resident/their represenatives which poses a potential personal rights risk to persons in care.
POC Due Date: 10/13/2026
Plan of Correction
1
2
3
4
ED agreed to ensure all reappraisals are reviewed with the resident and their representatives (if applicable) and signatures obtained. Proof of signed reappraisals will be sent to CCL by POC due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK PLACE CAMARILLO
FACILITY NUMBER: 565850778
VISIT DATE: 09/29/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and theater room in the Assisted Living side and activity room and dining room in the Meadows side. The LPA observed common areas to be clean and properly furnished at the time of the visit. A janitor's closet was observed to have a broken doorknob and the door closing mechanism was taped open during the visit, rendering the door unable to be closed. ED stated the key broke off in the door lock recently. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPA observed cameras in the common areas. The LPA observed the required postings in the common area.

OUTDOOR SPACE: The LPA observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use. During today’s visit, the LPA inspected the two (2) side delayed egress doors located in the Meadows; both delayed egress units were functional at the time of the visit. In the Memory Care unit outdoor area, the storage shed that houses the facility's trash was observed to be broken and overflowing with trash.

RECORD REVIEW: LPA reviewed 5 (five) staff and five (5) resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. Staff records reviewed contained all required documentation. LPA noted that the designated Administrator is no longer present in the facility and the ED has assumed the role approximately two (2) months ago, however, documentation was not received by the Department. All five (5) of five (5) resident files reviewed contained all documents, however, none of the reappraisals reviewed contained required signatures from the resident or resident’s responsible party.

MEDICATION REVIEW: Not observed during today's visit.

KITCHEN: Not observed during today's visit.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: Not observed during today's visit.

INTERVIEWS: Not conducted during today's visit.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC809 (FAS) - (06/04)
Page: 8 of 8