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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801019
Report Date: 10/28/2021
Date Signed: 10/28/2021 01:10:17 PM

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:MOUNTAIN VISTA OF OJAIFACILITY NUMBER:
565801019
ADMINISTRATOR:NICKIE PEREZFACILITY TYPE:
740
ADDRESS:602 EAST OAK STREETTELEPHONE:
(805) 646-6850
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:38CENSUS: 32DATE:
10/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Nickie PerezTIME COMPLETED:
01:09 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 10/17/21. LPA met with Administrator Nickie Perez.

On 10/20/21 LPA spoke with the Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 10/17/21. R1 was half a block away from the facility and was in someone else's home. Staff picked up R1 and they returned to the facility. R1 did not sustain any injuries. R1's primary care provider and family member were notified of the incident. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted.

During today’s visit LPA toured the facility with the Administrator and reviewed resident records. A review of R1's records at 12:20 pm revealed that R1 is not able to leave the facility unassisted.

During facility tour at 11:15 am with the Administrator LPA observed body wash in Building #2's shower room accessible to residents.

During facility tour at 11:19 am with the Administrator LPA observed Zinc Oxide ointment and perineum wash in R2's bedroom in Building #2 accessible to residents.

During facility tour at 11:21 am with the Administrator LPA observed body lotion in Building #2's front desk accessible to residents.

During facility tour at 11:24 am with the Administrator LPA observed stainless steel cleaner, dish detergent, grill and oven cleaner and 2 scissors in the kitchen in Building #1 accessible to residents.

During facility tour at 11:28 am with the Administrator LPA observed air freshener, shaving cream, a razor, shampoo and body wash in a restroom in Building #1 accessible to residents.

Continued on 809C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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
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: MOUNTAIN VISTA OF OJAI
FACILITY NUMBER: 565801019
VISIT DATE: 10/28/2021
NARRATIVE
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During facility tour at 11:31 am with the Administrator LPA observed foam hair mousse, perineum wash, shampoo and body wash in a restroom in Building #2 accessible to residents.

Interview with Administrator at 1:00 pm revealed that they will be conducting staff training today regarding safety and elopement protocols. Administrator stated that they also have additional staffing and provided an updated copy of their LIC500 Personnel Report. Administrator stated that they are in the process of getting delayed egress. Administrator stated that they have spoken with the Fire Inspector and will also submit the request to Community Care Licensing. Based on the information obtained during the investigation staff failed to supervise R1 on 10/17/21 as R1 eloped from the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, todays reports were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MOUNTAIN VISTA OF OJAI
FACILITY NUMBER: 565801019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
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Type A
10/29/2021
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA's observations, the licensee did not comply with the section cited above as over-the-counter medication, cleaning supplies and toxic substances were accessible to residents which poses an immediate health and safety risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: MOUNTAIN VISTA OF OJAI
FACILITY NUMBER: 565801019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a razor and scissors were observed accessible to residents which posed an immediate health and safety risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4