565850221-7-14-2026-29-AS-ECOZ-DVYVH4-20260714162632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 07/14/2026
Date Signed: 07/14/2026 04:27:37 PM

Document Has Been Signed on 07/14/2026 04:27 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 OJAI		FACILITY NUMBER:	565850221
ADMINISTRATOR/ DIRECTOR:	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: 18	DATE:	07/14/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Rafael Silva		TIME VISIT/ INSPECTION COMPLETED:	04:30 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) Esther Cortez alongside Tri Counties Regional Center Quality Assurance Specialist (QAS), Katy Robison conducted an unannounced subsequent Case Management-Incident inspection to follow up on a self reported Report of Suspected Elder Abuse SOC341 received. LPA and QAS initially met with staff and explained the reason for the visit. Executive Director Rafael Silva arrived shortly thereafter and was explained the reason for the inspection. On 07/07/2026, Community Care Licensing (CCL) received a self reported Report of Suspected Elder Abuse SOC341 regarding Resident 1 (R1) and a staff. It was reported that R1 alleged that a caregiver was rough with them, their hair was pulled, they were moved hard, and that they fell in the bathroom because they were pushed. Additionally, it was reported that R1 described the worker as a fat dark male by the name of Henry and works at night. On 07/09/2026, the LPA interviewed the ED, R1, five (5) staff, viewed video footage of the facility and collected pertinent documents relevant to the investigation. The ED revealed that a head to toe assessment for any physical changes had been performed on R1, and there weren't any changes. There were more staff the LPA needed to interview but they were not at the facility during that visit. On 07/14/2026, the LPA and QAS conducted one telephone interview with one staff. During today's visit the LPA and QAS conducted interviews with the ED and R1. The LPA reviewed R1's records. Report will continue on LIC809-C, 2nd page,

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI	FACILITY NUMBER: 565850221
	VISIT DATE: 07/14/2026

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A review of R1’s Physician Report, dated 10/09/2025, lists the resident's diagnoses as Dementia, Parkinson's disease, Major Depressive Disorder, Insomnia, Hypothyroidism, Hyperlipidemia, and Chronic Kidney disease. The report also notes a diagnosis of Major Neurocognitive disorder, specifying that while R1 can follow instructions, communicate needs, and feed themselves, they require staff assistance for self-care, repositioning, and transferring.

Facility record reviews and staff interviews revealed that no employee by the name of Henry works at the facility. All interviewed staff denied ever being rough, pulling hair, or pushing any residents, and they affirmed that they would report any witnessed abuse. During the night shift, only one male staff member (S1) is on duty. S1 denied any rough handling and noted that interactions with residents are minimal because they are asleep. The Licensing Program Analyst (LPA) reviewed overnight video footage from Friday, 07/03/2026, to Saturday morning, 07/04/2026. The footage showed S1 assisting R1 to the restroom twice; while the interior of the restroom is not visible on camera due to privacy, no resident distress was observed in the footage. Furthermore, the LPA interviewed R1 on 07/09/2026, and 07/14/ 2026. During the initial interview, R1 reported feeling very safe and well-treated, but provided contradictory statements about "Henry" pulling their hair, first stating they did not know who Henry was and later claiming he was staff. When interviewed again on 07/14/2026, and asked if any staff had ever hurt them, R1 replied, "No, that's ridiculous."

Based on the information gathered, there is no evidence to prove that a regulatory violation occurred at this time. No deficiencies are being cited at this time pertaining to this self-reported SOC 341. An exit interview was conducted, and a copy of the report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC809 (FAS) - (06/04)

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