567609954-3-29-2022-29-AS-KHEN-CCZUVX-20220330155552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 03/29/2022
Date Signed: 03/29/2022 11:55:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/17/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210617103535

FACILITY NAME:	ARTESIAN OF OJAI, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR:	BROWN, MARY THERESA		FACILITY TYPE:	740
ADDRESS:	203 E EL ROBLAR DRIVE		TELEPHONE:	(805) 798-9305
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	72	CENSUS: 38	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Mike O'Neill		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death/Neglect/Lack of Supervision: Facility Resident #1 (R1) sustained multiple falls resulting in R1’s death
Neglect/Lack of Supervision: Staff did not seek medical attention for R1 in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint visit to this facility to deliver final investigation findings. LPA met with Administrator Mike O'Neill.

On 06/17/2021, the Department received a complaint regarding an allegation of a questionable death. It was alleged that facility Resident #1 (R1) sustained multiple falls resulting in R1’s death and staff did not seek medical attention for R1 in a timely manner. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Olivia Spindola.

On 06/18/2021, from 11:42am to 2:42pm, Licensing Program Analyst (LPA) JoAnn Rosales conducted the initial 10-day complaint visit and met with Administrator Therese Brown. During the visit, LPA Rosales toured the facility with the Administrator, reviewed random resident records, interviewed random staff and resident, and obtained copies of pertinent documents. The LPA determined further investigation was required.
Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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 3

Control Number 29-AS-20210617103535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
	VISIT DATE: 03/29/2022

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
26
27
28
29
30
31
32

On 06/28/2021, from 11:45am to 1:50pm, Investigator Spindola conducted an interview with the Administrator, staff and residents; on 07/22/2021, at 1:00pm, left a voice message for the reporting party; on 08/10/2021, at approximately 11:00am, with the reporting party; and on 09/07/2021, at 4:45pm, with R1’s representative.

On 09/07/2021, at 3:45pm, Investigator Spindola contacted the Ojai Police Department and was informed that the agency did not contain any records that indicated they responded or completed any reports related to the investigation.

Investigator Spindola reviewed R1’s medical and hospice records. The records revealed that R1 was hospitalized at Ojai Valley Hospital on 01/11/2021 after falling out of wheelchair onto the right side of head and sustained a right forehead/eyebrow contusion; on 01/15/2021, R1 was hospitalized due to left shoulder pain; and on 01/27/2021, R1 was again hospitalized for several days. R1 suffered a fracture to the humerus bone in shoulder and returned to the facility under hospice care. On 02/16/2021, R1 passed away at the facility. The death certificate listed the death due to Cardiopulmonary Failure and underlying Alzheimer’s Disease.

R1’s representative stated the facility nurse always called when R1 suffered falls and was always sent to the hospital immediately after each of the falls. Staff assessed R1 after R1 sustained a fall, contacted the facility nurse, who instructed the staff to call 911 and have R1 transported to the hospital. The facility nurse denied directing any of the staff to not send residents to the hospital when they displayed health issues or sustained falls. Resident interview confirmed when residents get sick they are sent to the hospital.

Although the reporting party alleged that R1’s health declined and then passed away due to not being sent to the hospital after R1 sustained multiple falls, the medical records and witnesses’ statements do not support the allegation. Additionally, the allegations were reported two months after they allegedly occurred and the reporting party’s credibility regarding the allegations may be bias due to the reporting party’s history with the facility. Based on the information obtained, there is not sufficient evidence to support the allegations, therefore the allegations Question death/Neglect/Lack of Supervision - Facility Resident #1 (R1) sustained multiple falls

Continued on 9099C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210617103535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE	FACILITY NUMBER: 567609954
	VISIT DATE: 03/29/2022

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 26 27 28 29 30 31 32	multiple falls resulting in R1’s death and Neglect/Lack of Supervision - Staff did not seek medical attention for R1 in a timely manner, are deemed Unsubstantiated at this time. Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3