565801019-2-15-2024-29-AS-ECOZ-D2H3KS-20240215171937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801019
Report Date: 02/15/2024
Date Signed: 02/15/2024 05:20:54 PM

Document Has Been Signed on 02/15/2024 05:20 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MOUNTAIN VISTA OF OJAI		FACILITY NUMBER:	565801019
ADMINISTRATOR:	NICKIE PEREZ		FACILITY TYPE:	740
ADDRESS:	602 EAST OAK STREET		TELEPHONE:	(805) 646-6850
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	38	CENSUS: 23	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nickie Perez		TIME COMPLETED:	05:30 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	At 09:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Nickie Perez arrived shortly after. At 09:38 a.m. the LPA conducted a tour of the physical plant with Administrator Nickie Perez to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a residence that consists of two (2) buildings, with ten (10) resident rooms in each building. Building #2 is two stories and the second story is designated solely for staff. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 03/17/2023. At 12:05 p.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Water temperature measured in the restrooms in both buildings ranged between 108.6 degrees Fahrenheit and 118.6 degrees Fahrenheit. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VISTA OF OJAI	FACILITY NUMBER: 565801019
	VISIT DATE: 02/15/2024

NARRATIVE

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Common Areas: These included the dining areas and living areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies and toxins were observed locked and inaccessible. Surrounding Grounds (Outdoors)/Garage: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The garage is detached and locked at all times. No bodies of water were observed.
Infection Control: The community's policies and procedures pertaining to infection control were adequate.
Record Review: At 11:38 a.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/09/2023). The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of twenty-three (23) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The LPA identified that all five residents were missing the Consent for Emergency medical treatment form, (LIC 627C). Otherwise, all resident records were in order. The LPA reviewed five (5) of twenty-two (22) staff files. Personnel records and Administrator’s file were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA identified that three (3) of five (5) staff did not have a total of 20 hours of the annual required training which includes 8 hours of dementia training, and 4 hours which shall be specific to postural supports, restricted health conditions, and hospice care.
Interviews: During today’s visit, the LPA conducted six (6) resident interviews and four (4) staff interviews. No concerns voiced during the interviews.
Medications: At approximately 3:45 p.m. a medications review was initiated for two out of five residents and the following was observed. The medications were stored in a medication room and med carts which are locked and inaccessible to the residents. During Resident #2 (R#2's) audit, the LPA observed four (4) extra Metoclopramide 5 MG tablets, and two (2) extra Mirtazapine 15 MG ½ tabs based on start dates, and medication quantities documentation on the Centrally Stored Medication and Destruction Record (CSMDR). No change in orders were observed, and no refusals, or other reasons for medicine not being taken were observed on the Medication Administration Record (MAR) by the LPA and Administrator Teresa.

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.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VISTA OF OJAI	FACILITY NUMBER: 565801019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. 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 1 of 5 resident medications reviewed contained inconsistencies with their medication amounts remaining and quanties on the prescription labels which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/20/2024
	Plan of Correction
1 2 3 4	Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation 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.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 02/15/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VISTA OF OJAI	FACILITY NUMBER: 565801019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the section cited above in three out of five staff files indicate staff did not complete annual required training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee has agreed to ensure that all three staff complete annual training and send sign-in sheets to CCL by due date.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 in four (4) residents as they are missing the Consent for Emergency medical treatment form,(LIC 627C) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee will submit the completed LIC 627C,to LPA by POC date and will make sure all residents in the facility has the forms as well.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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