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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850778
Report Date: 05/20/2026
Date Signed: 05/20/2026 05:35:19 PM

Document Has Been Signed on 05/20/2026 05:35 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 DRIVETELEPHONE:
(818) 426-0886
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 130CENSUS: 57DATE:
05/20/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Stuart Montalvo & Gloria MoralesTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an announced pre-licensing visit to the facility noted above at 09:40AM. This is a change of ownership application. LPAs met with Applicants Janetta Chernega, Stuart Montalvo and Steve Kregel. An approved fire clearance was granted on 05/14/2026 clearing for a total capacity of one hundred thirty (130) residents of which one hundred ten (110) are for non-ambulatory residents and twenty (20) are for residents who are bedridden. All rooms are approved for non-ambulatory/bedridden residents. There is a pending hospice waiver for ten (10).

Facility Layout: The facility is a one-story building with one hundred seven (107) units. There is a secured memory care unit with approved delayed egress doors. There are twenty-three (23) resident rooms in the Memory Care Unit and eighty-four (84) rooms in Assisted Living. LPAs inspected ten (10) randomly selected resident bedrooms. Bedrooms are equipped with clean mattresses, pillows, bedding and have sufficient lighting. There is a sufficient supply of linens, including blankets, bath towels, and wash cloths. The facility has the following amenities and common areas: office spaces, beauty salon, the bistro, lobby, activity room, dining rooms, courtyards, theater, and library.

Common Spaces: Regarding the signal system, staff utilize walkie-talkies to communicate accordingly and all residents have pull cords in their rooms. There are cameras observed in the common areas and exterior perimeter. The community’s smoke detectors and carbon monoxide detectors are hard wired and were inspected by Ventura County Fire Protection on 12/24/2025 with no violations observed. LPAs observed fire extinguishers throughout the facility to be fully charged and last serviced on 04/09/2026. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. LPAs observed other required postings throughout the community.


Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2026
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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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARK PLACE CAMARILLO
FACILITY NUMBER: 565850778
VISIT DATE: 05/20/2026
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Bathrooms: Bathrooms were equipped with grab bars near the toilet and shower/tub, and slip-resistant surfaces were observed in the shower/tub. During today's visit, water temperature was tested in resident bathrooms, and all measured within the required range of 105 to 120 degrees F.

Grounds: LPAs observed appropriate outdoor furniture with a covered shaded area for residents. There was an enclosed courtyard for residents whom reside in the memory care unit. Passageways were free and clear from obstruction.

Kitchen: The community had a sufficient supply of perishable and nonperishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen by Assisted Living and is delivered to the Memory Care dining room.

Records: Beginning at 12:31PM, LPAs reviewed five (5) resident files and five (5) personnel files for required documents. Both resident and staff files were observed to be incomplete. During today's visit, a designee was present auditing all resident records. Management stated that all staff and resident files will be audited to ensure complete records are maintained.

Medications: There is a medication room in the assisted living section. Medications appeared to be documented on the centrally stored medication record and were present in the facility for self-administration. During today's visit, a designee was present auditing medications. Management stated that all medications and medication records will be audited to ensure compliance.

Physical plant is not consistent with the submitted facility sketch/floor plan as there are twenty four (24) bedrooms in memory care on the sketch, however there are twenty three (23) rooms present bedroom in memory care and eighty-six (86) bedrooms in assisted living on the submitted sketch that were not observed during the physical plant inspection. LPAs informed applicants to send the updated sketch to Centralized Application Bureau (CAB).

Comp III conducted with Applicant.

This report will be sent to CAB. You will be notified by the CAB Analyst when your license has been approved.

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

DATE: 05/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2026
LIC809 (FAS) - (06/04)
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