565850221-10-25-2023-29-AS-RDLN-CWY2GD-20231025172259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/25/2023
Date Signed: 10/25/2023 05:23:41 PM

Document Has Been Signed on 10/25/2023 05:23 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:	GLEN PARK AT OJAI		FACILITY NUMBER:	565850221
ADMINISTRATOR:	GARY Y LEE		FACILITY TYPE:	740
ADDRESS:	225 N LOMITA AVE		TELEPHONE:	(805) 646-2402
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	48	CENSUS: 15	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Leticia Hernandez, Back-up to Administrator		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 Analyst (LPA) De Leon arrived at 10:45 am to conducted a 1 year annual visit to the facility above. LPA met Back up to Administrator Leticia Hernandez and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has a sign in and out area for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. At 11:29 am LPA observed trash can and wastebaskets without tight fitting lids/covers. Files reviewed have some staff completing 2023 Infection control and PPE training. Operational Requirements: The facility has a current plan of operation. The facility is approved for a capacity of 48 capacity with 48 Non-Ambulatory, which 8 may be bedridden in rooms E10, E11, E12 and E13. Facility has a current Hospice wavier granted for 27. Delayed egress has been installed on front exterior door and 3 fence gates but is not currently being used until the fire clearance is granted. Front exterior door and gates were alarmed and are not locked LPA was able to open all doors/gates. At 10:45 am LPA observed video surveillance at front entry on tour of facility LPA observed 26 cameras total all in common areas of the facility. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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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: GLEN PARK AT OJAI	FACILITY NUMBER: 565850221
	VISIT DATE: 10/25/2023

NARRATIVE

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Physical Plant & Environmental Safety: The facility has an office, room 1 activity room, rooms 2 and 3 are used for show rooms, main living room, dinning room, kitchen, medication room, computer room, pantry, supply closet, 2 supply rooms 18 and upstairs room 201 and a staff break room upstairs in room 17. The facility has 2 levels with a total of 14 residents rooms downstairs and 4 resident rooms upstairs. Resident rooms have bathrooms and 4 restrooms currently occupying 15 residents and employs 21 staff. The facilities common areas were clean, safe and sanitary. LPA was authorized to enter and inspect facility. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facilities main kitchen is clean, safe and sanitary. Resident rooms were clean and comfortable for residents use. Restrooms have showers with non-skid mats and secured grab bars. Toilet, hand washing and bathing facilities were operational. The pathways were clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and kept locked. The facility has sufficient space inside and outside for activities and visiting. The facility is completely fenced with 3 self closing, self latching gates.. The outside courtyard has plenty of shade for resident use. The facility has telephone and internet service for all residents in care and can be accessed in the computer room. LPA toured 10 resident rooms and all rooms met regulation requirements.

Staffing: The facility employes 20 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expires 04/18/2024.

Personnel Records & Training: The facility keeps confidential files for each staff member. At 2:30 pm LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and staff met most requirements with some not meeting exact hours and or subjects requirements. Administrator will make sure all staff finish annual training for 2023 with all required subjects and topics covered with documents containing all required information. Staff handling medications had annual training of 8 hours of medication training. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI	FACILITY NUMBER: 565850221
	VISIT DATE: 10/25/2023

NARRATIVE

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Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals were on file. The facility does handle cash resources. The facility Surety Bond expires on 06/15/2024. Facility does submit incident reports to the department when required.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. CCL Complaint poster and LTCO poster was posted in the front entry area of the facility. The current license was posted in common entryway.

Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room.

Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food was covered, stored and marked appropriately in the main kitchen. A menu is posted for residents in care. Cleaning solutions and equipment were stored separately than food supply. Main Kitchen areas were clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical & Dental: The facility has 1 locked medication room. Facility provides or arranges transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected prescription and PRN medications. Medications were reviewed for expirations dates and no medications labels were altered. The facility has a red sharps container for disposal of syringes. Medication destruct is done by the facility Administrator and Medication Technician.
Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI	FACILITY NUMBER: 565850221
	VISIT DATE: 10/25/2023

NARRATIVE

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Disaster Preparedness: The current emergency disaster form is posted. The fire extinguishers were charged and last inspected on 09/22/2023. Emergency exits and telephone numbers were posted. Facility is conducting quarterly disaster drills. The facility annual fire inspection was completed on 05/22/2023 and facility had a compliance date of corrections for 06/22/2023. Fire inspection has not been completed for the compliance and will be coming back out to the facility for delayed egress, fire rated assemblies, resident rooms labelled to reflect numbers on facility sketch, emergency exiting sign and lighting, removal of magnetic lock on dining room. Facility has complied with all except the delayed egress that is not being utilized at this time until all requirements are met and it is approved for use.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does have delayed egress installed but it is currently not being utilized until approved by Fire clearance and CCL. The facility had exiting door alarm as well as exiting gate alarms. The facility does not currently have residents with oxygen. The facility currently has 1 hospice resident and 10 residents receiving home health services. All rooms and bathrooms have emergency pull cords to alert staffing.

Exit interview conducted and copy of report printed to back up Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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