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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850221
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:01:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240313134850
FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:GARY Y LEEFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:48CENSUS: 16DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Hollyn Heron-Activity Director/Roman Sierra Tovar-EDTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff caused an injury to a resident
Staff mishandled a resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. Upon arrival, LPA met with Activity Director Hollyn Heron and explained the reason for the visit. Executive Director (ED) Roman Sierra Tobar was unable to be at the facility during today’s visit, was explained the reason for the visit via phone and authorized Holyn Heron to sign and receive the report. However, ED arrived as LPA was issuing findings.

On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two (2) staff and obtained pertinent documents relevant to the investigation. On 08/14/2024, the LPA conducted one (1) staff telephone interview. Report will continue on LIC9099-C (2nd page).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240313134850

FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:GARY Y LEEFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:48CENSUS: 16DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Hollyn Heron-Activity DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff admitted a resident with a prohibited health condition
Staff did not perform appropriate assessment for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit to deliver findings for the above allegations. Upon arrival, LPA met with Activity Director Hollyn Heron and explained the reason for the visit. Executive Director (ED) Roman Sierra Tobar was unable to be at the facility during today’s visit, was explained the reason for the visit via phone and authorized Holyn Heron to sign and receive the report. However, the ED arrived as LPA was issuing findings.

On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two (2) staff and obtained pertinent documents relevant to the investigation. On 08/14/2024, the LPA conducted one (1) staff telephone interview. Report will continue on LIC9099-C (2nd page).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/29/2024
NARRATIVE
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On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. On 10/09/2024, the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m.

On the allegations "Staff admitted a resident with a prohibited health condition" and “Staff did not perform appropriate assessment for a resident”; it is the concern of the reporting party (RP) that Resident #1 (R1) was admitted to the facility on 02/19/24 and then asked to leave the facility the following day on 02/20/24 due to wounds that might violate licensing requirements. RP further reported that the wound in question was located on the residents’ leg, and they were Venous stasis and not a pressure wound, however the Administrator at the time believed they were a stage 3 pressure wound. Lastly, the RP reported that the facilities Administrator and additional staff had performed a pre-placement assessment on R1 prior to admitting them and should have caught the prohibited health condition if it was a stage 3 pressure wound. To investigate the allegation the LPA conducted a file review and interviews.

A review of R1’s head-to-toe assessment form for any physical change, dated 2/14/2024, and completed by facilities Administrator and Retirement Counselor indicated that R1 had sign of redness or sore around the ankle area, however it did not indicate if it was a pressure injury. Additional assessment forms signed by previous Administrator Gary Lee indicated that they did not have any concerns regarding R1’s care plan. A review of R1’s physician’s report, dated 02/13/2024, indicated R1’s primary diagnoses was listed as cellulitis of left upper limb, and secondary diagnosis was listed as chronic kidney disease, stage 3A. The report indicated R1 had mild cognitive impairment, was able to follow instructions as well as communicate needs, and had history of skin condition or breakdown. R1’s physician report did not indicate any pressure injuries. A review of R1’s, Shoreline Care Center, skilled nursing facility records, dated 02/19/2024, obtained from Glen Park at Ojai indicated some of R1’s diagnoses were listed as cellulitis of left upper limb, venous insufficiency (chronic), non-pressure chronic ulcer of unspecified part of right lower leg with unspecified severity, among other diagnosis, however pressure wounds of any stage were not listed as a diagnosis.

Interviews with Administrator Gary Lee revealed that on 02/14/24 they and the Retirement Counselor had performed a pre-placement assessment on R1, prior to admitting them to the facility. Administrator Gary Lee revealed they looked for injuries, they did a head-to-toe, and looked to see if R1 had any open skin.

Report will continue on LIC9099-C (3rd page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/29/2024
NARRATIVE
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Administrator saw a band-aid on R1’s left arm, and bandages on both legs; the Administrator removed the band-aid on the arm and asked for the bandages on the legs to be removed and revealed that they saw pinkness on R1’s arm and pinkness and scabs with cream on the legs and asked for the cream to be removed. Administrator Gary Lee further revealed that they were informed by the skilled nursing facility staff that the right injury on R1’s leg came from a fall R1 had, and the injury on the left leg looked the same but he was told that it looked reoccurring. The administrator observed a scab on the left leg injury that was solid black that raised above the skin, and although he didn’t measure, he believed it was about 3cm. Furthermore, Administrator Gary revealed that they asked for R1’s physician’s report, R1’s left leg was not mentioned in the report, they thought R1’s skin integrity was healed as they saw a scab on it and thought R1 was appropriate to move into the facility. Lastly, Administrator Gary Lee revealed that after R1 was admitted to the facility, on 2/20/2024, a MedTech (MT) was cleaning R1’s dressings, and when they took the dressings off the left leg with the reoccurring wound, the scab fell off. The MT called him to look at the wound, when he saw it, he believed it was a stage 3 wound due to being an open sore that is past the skin and being able to see flesh; he then informed R1’s authorized person that R1 could not be at the facility due to having a stage 3 wound. Administrator Gary Lee is not a medical professional. Administrator Gary Lee went on to reveal that a home health nurse staged the wound as a stage 3, however, facility staff was not able to provide any records for that nurse’s home health visit.

On the allegations “Staff admitted a resident with a prohibited health condition" and “Staff did not perform appropriate assessment for a resident”. The Department’s investigation revealed R1 had a history of numerous health conditions including non-pressure chronic ulcer of unspecified part of right lower leg, however, R1 did not have any open wounds during the assessment and did not have any prohibited health conditions upon admission to the facility. Any open wounds R1 obtained were after they were admitted to the facility. Administrator Gary Lee performed an assessment for R1 and based on his observations and records that were provided to him at the time of the assessment, he believed R1 was a good fit for the facility. The information and evidence obtained during the investigation did not sufficiently support the allegations, therefore, the allegations are deemed Unsubstantiated at this time.

Exit interview conducted. Today's report was reviewed and provided to the Executive Director.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/29/2024
NARRATIVE
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On 10/04/2024, the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m. On 10/09/2024, the LPA conducted a file review, three (3) staff interviews, one (1) phone interview with Mission Hospice representative between 10:45 a.m. and 3:30 p.m.

On the allegation "Staff caused an injury to a resident"; it is the concern of the reporting party that on 02/20/2024, Resident #1 (R1) acquired a new gash to their lower left leg, and facility staff said R1’s leg was caught on wheelchair during transfer, and R1 said a caregiver’s thumb went through their skin and tore a gash in lower left calf. To investigate the allegation the LPA conducted file review and interviews.

A review of R1’s physician’s report, dated 02/13/2024, indicated R1’s primary diagnoses was listed as cellulitis of left upper limb, and secondary diagnosis was listed as chronic kidney disease, stage 3A. The report indicated R1 had mild cognitive impairment, had motor impairment/ paralysis (weakness), was able to follow instructions as well as communicate needs, and was identified as non-ambulatory. A review of R1’s appraisal/needs and services plan, dated 02/19/2024, indicated R1 was a fall risk, needed help with mobility, bathing, dressing, and toileting, had MCI, was talkative and social, and was not aggressive and not a wanderer.

Staff interviews revealed that R1 sustained an accident at the facility during a transfer. Interview with previous Administrator Gary Lee, revealed that Staff #1 and #2 (S1, S2) forgot to remove the wheelchair footrest when transferring R1 from a recliner to their wheelchair. R1 was very frail, both staff were at both sides of the resident, but when they were lifting R1 up, R1’s left leg got caught with a screw on the leg of the footrest and it caused a gash right above R1’s existing wound. LPA Cortez was not able to interview R1 or S1. Interview with S2 revealed that they witnessed R1’s accident, however they did not see exactly how everything happened. S2 revealed R1 was trying to get up from a recliner in the living room, S1 had R1 in their hand trying to transfer R1 to a wheelchair, at one point S2 asked S1 “What are you doing?” because two people should have been assisting R1, and the wheel chairs legs were up and S1 did not realize that the wheel chair legs was what cut R1. S2 stopped what they were doing and went over to check on them and notice blood and had to bandage R1’s new cut. S2 revealed R1’s injury could have been prevented by removing the legs from the wheelchair and by having two staff assisting R1.

Report will continue on LIC9099-C (3rd page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/29/2024
NARRATIVE
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Interview with Administrator Gary revealed that R1 was a one person assist, however interview with the Assistant Administrator revealed that R1 was a fall risk, and typically fall risk residents are a two person assist. Furthermore, four (4) staff revealed that R1 was a two-person assist, and one staff revealed that although they were not present during R1’s accident they were informed that staff attempted to transfer R1 without assistance and that led to R1’s fall, while other staff revealed they heard staff had dropped R1.

On the allegation “Staff caused an injury to a resident,” the Department’s investigation provided sufficient evidence to substantiate the allegation. Based on staff interviews, it has been determined S1 failed to remove the wheelchair’s leg and failed to obtain a second person to assist when transferring R1 from a recliner chair to their wheelchair resulting in R1 sustaining a gash (skin tear) to their left leg, therefore, the allegation is deemed Substantiated at this time.

On the allegation "Staff mishandled a resident's medication"; it is the concern of the reporting party that Resident’s #1 (R1) was not receiving all their medications due to R1’s Rx hemorrhoid cream for their chronic rectal prolapse not being with R1’s medication when they were collected. It was further reported that the medication had to be further searched for by a MedTech to be returned to R1’s responsible person and that the medication was not listed with R1’s inventory of medications. To investigate the allegation the LPA conducted file review and interviews.

A review of R1’s, Shoreline Care Center, skilled nursing facility Order Review Report, dated 02/19/2024, obtained from Glen Park at Ojai indicated R1 was prescribed Anusol-HC External Cream 2.5% (Hydrocortisone), with an order date and start date of 02/16/2024. Per the order summary, “apply to rectum topically one time only for hemorrhoids for 1 Day start once available and apply to rectum topically every day shift for hemorrhoid.” A review of the facilities Medication Transfer sheet/Release of Responsibility form, dated 02/19/2024, revealed that R1’s Anusol-HC External Cream 2.5% (Hydrocortisone) was not listed in the inventory list of medications obtained from R1’s family. However, review of the facilities Medication Transfer sheet/Release of Responsibility form, dated 02/22/2024, revealed that two tubes of hydrocortisone were released back to R1’s responsible party by Staff #3 (S3). A review of R1’s Medication/Treatment Administration Record (MAR) from the facility for February 2024, revealed that R1’s hemorrhoid medication was not listed as one of the medications administered to R1 during their time at Glen Park at Ojai.
Report will continue on LIC9099-C (4th page).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/29/2024
NARRATIVE
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Interview with previous Administrator Gary Lee revealed that R1 was admitted with medication provided by Shoreline Care Center and medication provided by R1’s family and there was some kind of ointment or cream for R1 (name not provided), but it was already expired, and they could not use. However, staff were unable to provide R1’s Centrally Stored Medications and Destruction Record (CSMDR). Interview with S3, revealed that when R1 was being discharged, and they were returning R1’s medication, R1’s family mentioned there was additional medication. S3 asked Administrator Gary Lee about the additional medication, and Mr. Lee let them know that there was additional medication, and they gave the medication back to the family. S3 does not believe the cream was administered to R1 but is not certain and believes that they did not have a doctor’s order for the cream. On 10/09/2024, the LPA and S3 reviewed R1’s MAR, R1’s hemorrhoid medication was not listed, and S3 advised the LPA that all medicines administered to the resident would be on the MAR, however they were using a different MAR when R1 was at the facility, and it got transfer to the new MAR. Staff was not able to provide R1’s original MAR.

On the allegation, “Staff mishandled a resident's medication”; the Department has sufficient evidence to substantiate the allegation. Based on record review and interviews conducted, it has been determined that staff failed to administer R1’s Anusol-HC External Cream 2.5% (Hydrocortisone) during their stay at the facility, despite having it and having an order from the skilled nursing facility, additionally staff failed to provide R1’s CSMDR, therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited, and civil penalty is being issued (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2024
Section Cited
HSC
1569.312(a)
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HSC 1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by:
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S1 is no longer working at the facility. Licensee will submit a plan how they will ensure staff to properly transfer residents. Submit to CCL by due date.
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Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to properly transfer R1 which caused R1 to sustain a skin tear on their left leg. This posed an immediate health and safety risk to residents in care.
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Type A
10/30/2024
Section Cited
CCR
87465(a)(4)
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CCR 87465(a)4 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by:
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Licensee agreed to review section cited and submit a statement of understanding, how they plan to ensure residents will receive their medications as prescribed, and how they will ensure staff properly documents medication on the CSMDR and submit to CCL by POC due date.
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Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 and failed to provide R1’s CSDMR which posed an immediate health and safety concern 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8