565801114-6-2-2023-29-AS-ECOZ-CSF294-20230602171120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801114
Report Date: 06/02/2023
Date Signed: 06/02/2023 05:14:18 PM

Document Has Been Signed on 06/02/2023 05:14 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:	MANOR OF OJAI, THE		FACILITY NUMBER:	565801114
ADMINISTRATOR:	HALINA GARBACZ		FACILITY TYPE:	740
ADDRESS:	108 W. EUCALYPTUS ST.		TELEPHONE:	(805) 646-1489
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	44	CENSUS: 9	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:32 PM
MET WITH:	Halina Garbacz		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	Licensing Program Analysts (LPA’s) Esther Cortez and Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 12:32 p.m. The LPAs were greeted by administrator Halina Garbacz and informed them of the reason for the visit. Today, a tour of the physical plant with Administrator Halina Garbacz was initiated at 12:35 p.m. and the following was observed: Kitchen At 12:40 p.m. the LPAs observed the kitchen to be kept inaccessible to the clients. There were adequate supplies of both perishable (2 days) and nonperishable (7 days) food to accommodate the current capacity of nine (9) clients. The LPAs observed the following expired food in the pantry: Four (4) boxes of cake with the expiration date of February 2023 One (1) Cake mug treat with the expiration year of 2020 One (1) pasta noodle bag with the expiration date of April 2022 One (1) pasta noodle bag with the expiration date of July 2022 Four (4) boxes of graham crackers with the expiration date of March 2023 Two (2) bottles of yellow mustard that required refrigeration with the expiration year of 2021 LPAs observed the following expired food in the refrigerator: One (1) Tub of Mayonnaise with the expiration date of May 2023 One (1) Sunny D juice bottle with the expiration date of February 2023. Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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Document Has Been Signed on 06/02/2023 05:14 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 fifteen (15) food items in the food pantry were expired which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	Licensee agrees to complete a food audit to ensure all food is of good quality and discard all expired food items. Complete audit by the end of day on 6/3/2023 and informed CCL when audit is complete not later than the POC due date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 the LPAs observed pliers accessible to the residents., which poses an immediate health, and safety risk to persons in care.
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	The licensee agrees to secure and lock all tools to ensure all items listed above are inaccessible to the residents. Complete and submit proof to CCL by the POC due date. Proof can be photos or a self certification.

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	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2023 05:14 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the LPAs observe shovels, fertilizer, rakes, gardening supplies, and soil in the courtyard accessible to the residents, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	The licensee agrees to secure and lock all tools to ensure all items listed above are inaccessible to the residents. Complete and submit proof to CCL by the POC due date. Proof can be photos or a self certification.

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to ...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 as the water temperature in resident bathrooms up to 137.8 degrees F which poses an immediate health and safety risk to persons in care
	POC Due Date: 06/03/2023
	Plan of Correction
1 2 3 4	Staff adjusted the water temperature during the visit. The administrator shall complete a 5-day water temperature log which indicates the water temperature is within the required range of 105-120 degrees and submit proof to CCL by 06/28/2022.

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	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
	VISIT DATE: 06/02/2023

NARRATIVE

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The Administrator stated the Sunny D juice bottle had been refilled with Tang powder and water and that the juice was not expired. The LPAs advice the administrator to use refillable pitchers instead. The Administrator discarded all expired food items listed upon observation. The LPAs observed food containers not properly labeled with expiration dates in the refrigerator. There was a sufficient supply of cooking and dining ware. There were no visible immediate hazards observed.

Dining Room: At 12:47 p.m. the LPAs observed the dining room to be appropriately furnished to accommodate the current capacity of 9 clients. LPAs observed pliers inside a drawer of the coffee station. Upon observation the administrator removed the pliers. There is a fireplace located in the dining room properly fenced and with no tools. The LPAs observed four (4) wood bars on top of a chair in the corner of the dining room. The Administrator removed these wood bars upon observation. The LPAs also observed two parrot cages and the floor underneath one of the parrot cages was unsanitary.

Bedrooms: There were twenty-two (22) bedrooms designated for clients use. At 12:50 p.m. LPAs audited eight (8) out of twenty-two (22) resident rooms. The LPAs observed all bedrooms to be furnished appropriately with clean linens, and appropriate furnishings. The LPAs observed all bedrooms to be unlocked.

At 1:09 p.m. in bedroom #21 the LPAs observed more than ten (10) medicine bottles on top of the night stand next to the bed and a personal shaver on top of the resident’s vanity. The Administrator indicated that this resident was independent and could manage their own medications. However, the LPAs advised the Administrator that the personal care items and medications would either need to be kept in a locked box, or the resident could be advised to lock their room, to ensure other residents would not have access to their personal care items.

Bathrooms: Bedrooms either had an attached shared bathroom designated for the client residing in each
bedroom or single half bathrooms attached to the bedroom. The LPA’s conducted water temperature checks
In random bathrooms between 12:35 p.m. through 01:25 p.m., and the hot water measured ranged between 90.6 degrees F to 137.8 degrees F.

Report will continue on LIC809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
	VISIT DATE: 06/02/2023

NARRATIVE

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The LPAs observed the following in the bathrooms during the tour:
At 12:54 p.m., the LPAs observed the shower floor unsanitary of the shared bathroom between rooms #3 and #4.
At 12:59 p.m. the LPAs observed personal care items (shampoo and body wash), and the toilet with feces stains in the shared bathroom between rooms #5 and #6.
At 1:07 p.m. there was an unlocked shower room with personal care items, (shampoo, conditioner and body wash).

Common Areas: There is a large activity room appropriately furnished to accommodate the current capacity of nine (9) clients. There is a television, piano, puzzles and other indoor activities available for clients use. There is a fireplace properly fenced. The room appeared clean and there were no immediate visible hazards.

Outdoor courtyard: At 1:15 p.m. the LPAs observed the outdoor courtyard that is accessible to the clients. The backyard has furniture appropriate for outdoor use and designated for clients. There are five (5) tables with sunshades and a garden area. There were no bodies of water observed. The LPAs observed the laundry room unlocked with detergent accessible to the residents. The LPAs also observed pliers, shovels, fertilizer, rakes, gardening supplies, and soil in the courtyard accessible to the residents.

Due to time constraints, the LPAs will return at a later date to complete the inspection.

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, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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