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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801114
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:44:12 PM


Document Has Been Signed on 06/14/2024 12:44 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:MANOR OF OJAI, THEFACILITY NUMBER:
565801114
ADMINISTRATOR:HALINA GARBACZFACILITY TYPE:
740
ADDRESS:108 W. EUCALYPTUS ST.TELEPHONE:
(805) 646-1489
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:44CENSUS: 11DATE:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator - Halina Garbacz TIME COMPLETED:
01:41 PM
NARRATIVE
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 At 8:00am on 06/14/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct that annual facility inspection. LPA met with administrator Halina Garbacz announced who he is and the reason for the visit.
This facility has twenty-two resident rooms are set up for double resident occupancy, however all rooms are currently single occupancy do to current census numbers. There is a large TV/Activity room a larger community dining/activities room, commercial kitchen, and 8 assorted office rooms for multi functional use including a full office for medication room (clinic), which also has a full first aide kit. And there are two public restrooms, a hallway shower room and one side of the facility has jack and Jill bathrooms, the other side has on suite bathroom all of which were observed and to be in regulation compliance. This facility has a large open center court yard and a large garden and yard are on the south side of the building with several areas of shade for residents and visitors. LPA was able to observe 11 of 22 resident rooms all outfitted within regulation standards. LPA noted the water at two locations on opposite sides of the facility were both within regulation standards. LPA noted several fire extinguishers located throughout the facility all primed and charged in the green indicating functional. LPA observed at least two days of perishable foods and at least 7 days of non perishable foods for at least 11 residents and staff. LPA noted that all walkways and all doors and windows were free and clear of debris. LPA conducted a sample medication audit and review staff and resident files. LPA noted that there were no violations or citations noted during the facility full physical walk through.
Administrator and LPA conducted a full review and the annual control tools modules. LPA noted one citation in Operational Plan Requirements pertaining to Dementia information in facilities plan of operation. LPA cited and advised Administrator on corrective measure for this citation. LPA note no other violations, technical, or citations issued on the full annual inspection.

Exit interview, report read, citation and appeal right issued, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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Document Has Been Signed on 06/14/2024 12:44 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

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 in count 1 of 1 [which dementia information was not in the plan of operation or on the facility license while accepting resident with dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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Licensee will submit an addendum to the facility plan of operations including dementia care that the facility will conduct on normal operations. licensee will email addendum and request to assigned LPA and will follow up with daily duty officer and or designated LPA as needed until addendum is approved.
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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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