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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801309
Report Date: 11/10/2020
Date Signed: 11/10/2020 02:08:57 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:OLIVE BRANCH OF OJAI, THEFACILITY NUMBER:
565801309
ADMINISTRATOR:PHILLIP WOODALLFACILITY TYPE:
740
ADDRESS:506 DROWN AVENUETELEPHONE:
(805) 646-2364
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:6CENSUS: 0DATE:
11/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Deborah WoodallTIME COMPLETED:
11:26 AM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a case management visit virtually with licensee Deborah Woodall due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 9/30/2020 LPA spoke with licensee Deoborah Woodall who stated that they were planning on closing the facility. This was the first notification from the licensee that Community Care Licensing received regarding the facility closure. On 11/9/2020 LPA received an email from the licensee with copies of eviction notices dated 10/1/2020 to the 5 residents of the facility along with the relocation locations for the 5 residents. LPA observed that the eviction notices did not include the following: right of the residents or the resident's legal representative to contact the department to investigation the reasons given for the eviction pursuant to Section 1569.35, the contact information for the local long-term care ombudsman, including address and telephone number.

During today’s visit, LPA toured the facility and observed that there were no residents in care residing at the facility. Licensee indicated that they will mail the facility license to Community Care Licensing Woodland Hills office.



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

A telephonic exit interview was conducted with the licensee, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OLIVE BRANCH OF OJAI, THE
FACILITY NUMBER: 565801309
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2020
Section Cited

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Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties.(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility...
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 the eviction letters did include all the requirements of H&S 1569.682 which poses a potential personal rights risk 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: 11/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2020
LIC809 (FAS) - (06/04)
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