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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800360
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:11:49 PM

Document Has Been Signed on 08/10/2023 04:11 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARC-OJAI ENRICHMENT CENTERFACILITY NUMBER:
565800360
ADMINISTRATOR:AMBER LUNDEENFACILITY TYPE:
775
ADDRESS:210 CANADATELEPHONE:
(805) 646-5186
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 105CENSUS: 40DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Amber LundeenTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 8:50 a.m. The Facility is vendored by Tri-Counties Regional Center. The LPA met with Administrator Amber Lundeen and explained the reason for the visit. Upon arrival, there were forty (40) consumers and fifteen (15) staff. The program currently operates from 8:00 a.m. to 2:00 p.m. The day program was staffed with 1:3 staff to consumer ratios and two 1:1 staff to consumer ratios.

At 9:00 a.m., the LPA and the Administrator Amber toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Activity Space: The facility is a single-story structure with a gallery room, Rec room, art room, sensory room, event room, music room, two offices, two bathrooms, and a food service area. The LPA did not observe any obstructions or hazards during the inspection. The program site appeared to be clean, safe, sanitary, and in good repair at this time. The LPA observed fire extinguishers throughout the facility, which were last serviced 09/26/2023. The smoke alarms and carbon monoxide detectors were tested throughout the tour and at 9:08 a.m. the smoke detector in the Case Managers office was observed to not have batteries and inoperable. Upon observation the administrator installed batteries. Cleaning supplies are stored in a locked area.
Activities: Activities are both designed for individual and as a group. Activity supplies were observed in all the rooms.
Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers. At 9:13 a.m. the kitchen was observed to have a smoke detector inoperable. Upon observation the administrator installed new batteries and the smoke detector functioned.

Report will continue on LIC809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARC-OJAI ENRICHMENT CENTER
FACILITY NUMBER: 565800360
VISIT DATE: 08/10/2023
NARRATIVE
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Restrooms: The two restrooms were observed to be clean and sanitary with a hand soap and paper towels. The hot water temperature in the restroom was tested at 09:25 a.m., and it measured at 93.3 degrees Fahrenheit.

Record Review: At 10:25 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, Insurance liability and last fire drill (conducted on 06/19/2023). The LPA obtained Client and Staff Roster. At 11:30 a.m. the LPA reviewed five (5) of fifteen (15) staff files. All staff documents reviewed appeared complete and current. The LPA reviewed five (5) of forty (40) Client Files. One out of five clients (C1) did not have a needs and services plan (ANS) or an individualized program plan (IPP) on file. Four out of five clients (C2, C3, C4, C5) did not have their ANS’s or IPP’s updated annually in 2023 and 2022.

Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility's procedures as it pertains to infection control are adequate.

Interview: During today's visit, at 1:00 p.m. the LPA interviewed five (5) staff and five (5) consumers. No immediate concerns voiced at this time.

Medication Audit: A medication audit for five (5) clients was initiated at 2:00 p.m. and the
following was observed. The medications were stored in a locked cabinet inside the gallery room and
inaccessible to the clients. During Client #6 (C6's) audit, the LPA observed two bubble packs for Carbamazepine and Risperidone filled for the month of July and May being used. Upon observation the administrator stated that the client’s admission to the facility was mid-month and therefore two medication bubble’s pack were being used. In addition, the administrator also stated that C6’s home has not sent in new medication for the month of August.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/10/2023 04:11 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/10/2023 at 03:38 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: ARC-OJAI ENRICHMENT CENTER
FACILITY NUMBER: 565800360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the kitchen and case managers office did not have operable smoke detectors which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Upon observation, the administrator replaced the batteries on both smoke detetors during the time of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/10/2023 04:11 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/10/2023 at 03:38 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: ARC-OJAI ENRICHMENT CENTER
FACILITY NUMBER: 565800360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the hot water in one of the bathrooms was measured at 93.3 degrees F which poses a potential health and safety risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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The administrator agrees to adjust the water temperature and start a hot water temperature log testing the water once a day for five days. The administrator will submit the hot water log to CCL by no later than 8/18/2023
Type B
Section Cited
CCR
82068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in five out of five clients as one client did not have a needs and services plan and four clients did not have needs and services plans for the years of 2022 and 2023 which poses a potential health and safety risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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The administrator agrees to ensure all clients have an updated needs and services plan and submit proof to CCL by no later than 8/25/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5