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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 07/01/2020
Date Signed: 07/01/2020 05:47:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:OJAI VALLEY ASSISTED LIVINGFACILITY NUMBER:
567609954
ADMINISTRATOR:BROWN, MARY THERESAFACILITY TYPE:
740
ADDRESS:203 EL ROBLAR DRIVETELEPHONE:
(805) 628-3132
CITY:OJAISTATE: CAZIP CODE:
93001
CAPACITY:72CENSUS: 0DATE:
07/01/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Therese Brown and Michael WeyrickTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) JoAnn Rosales initiated a pre-licensing/Tele-TA facility virtual visit simultaneously. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Therese Brown the facility administrator and Michael Weyrick applicant representative. This is a new facility.

The applicant successfully completed Component II on 03/08/2018 and Component III was conducted in conjunction with this pre-licensing visit.

BEDROOMS: The physical plant was toured inside and out. A fire clearance is pending approval for a capacity of 72 non-ambulatory residents. This facility has 4 resident buildings each with 14 private resident bedrooms and 2 – 1-bedroom units that are capable for double occupancy as needed. Buildings 3 and 4 are set up with delayed egress for memory care. Each building has its own dining room and kitchen. Model rooms are set up with beds, night stands, lamps, chests of chests of drawers, chairs and closet space. Lighting in the rooms was adequate. Signal system was tested and operable.

BATHROOMS: There are 64 resident bathrooms. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid materials. Resident medications will be kept in a locked medicine cabinet in resident bathroom. Administrator was unable to test water temperature during facility visit as gas was not turned on.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. LPA observed fire extinguishers charged. The facility smoke alarm system is hard wired. Smoke alarms and carbon monoxide detectors were tested and operable.

Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020
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, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME: OJAI VALLEY ASSISTED LIVING
FACILITY NUMBER: 567609954
VISIT DATE: 07/01/2020
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NURSES OFFICE: Resident records and narcotics will be kept in locked medication room.

ADMINISTRATOR'S OFFICE: Staff records will be kept in a locked cabinet in the Administrators office.

KITCHEN: Kitchen appliances were in operable condition. The facility had a sufficient supply of non-perishable food. The supply of dishes was adequate. Cleaning supplies will be stored in the utility building.

OUTSIDE AREAS: Swimming pool located in center courtyard. LPA observed fencing around the perimeter of the pool with keypad entrance gates

MEMORY CARE: Building 3 Matilija Hall and Building 4 Topa Topa will both have delayed egress.

The following items are needed prior to issuance of license.

1. Approved fire clearance.
2. 3 day water temperature log indicating water temperature between 105 - 120 degrees Fahrenheit.
3. Picture of emergency contact phone numbers posted.
4. Picture of emergency lighting supplies
5. Documentation of delayed egress on back door of building 3 Matilija Hall in working order.


This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. A telephonic exit interview was conducted with applicant, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2020
LIC809 (FAS) - (06/04)
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