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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/02/2024
Date Signed: 10/02/2024 04:34:55 PM


Document Has Been Signed on 10/02/2024 04:34 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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:
10/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Roman Sierra TovarTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit due to three self-reported incidents of medication being found on the floor in three residents' rooms. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison. LPA explained the reason for the visit to acting administrator Roman Sierra Tovar.

At 1:38 LPA and QAS spoke with administrator. At 1:50 p.m. LPA and QAS reviewed and obtained pertinent documents. At 2:04 p.m. LPA and QAS conducted a brief tour of the facility. At 2:12 LPA and QAS interviewed medication technician staff 1 (S1).

On 9/18/2024, a medication technician found a medication on the floor in the room of resident 1 (R1). On 9/20/2024, a medication technician found a medication on the floor in the room of resident 2 (R2). On 9/23/2024, a medication technician found a medication on the floor in the room of resident 3 (R3).

S1 stated they always make sure all medication is taken by a resident before they leave the room. S1 is not on the same shift as other medication technicians so they were not sure how other medication technicians distribute medications. S1 found a medication on the floor, properly discarded the medication and reported it to management.

R1, R2, and R3 all have physicians' reports which state they cannot have access to medication.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC809-D).
Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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 10/02/2024 04:34 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 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: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2024
Section Cited
CCR
87465(h)(1)(B)

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87465 Incidental Medical and Dental Care (h) The following requirements... which are centrally stored: (1) Medications shall be centrally stored...: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.
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Administrator will ensure all medication technicians are immediately told they must ensure all medications are taken by residents before leaving the room. Formal training will be conducted and evidence of the training will be sent to CCL on or before 10/9/2024.
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This requirement was not met as evidenced by: Based on record review, R1, R2 and R3 cannot have access to medications but all had medication found in their room, which poses an immediate health and safety risk to residents 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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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