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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:27:05 PM

Substantiated


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
05/04/2022 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20220504151158
FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR:MICHAEL O'NEILLFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:72CENSUS: 42DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michael O'NeillTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility staff did not notify the resident’s authorized representative of a change in the resident’s condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced subsequent visit to deliver the final findings to the above facility. LPA met with Administrator Michael O'Neill at 11:30 a.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 05/04/2022 alleging that facility staff did not notify the resident’s authorized representative of a change in the resident’s condition. On 05/05/2022, LPA Ascencio conducted an interview with Director of Health Services (DHS) starting at 2:45 p.m. During DHS interview, it was revealed that Resident #1 (R1) started presenting with bed sores early in April 13th. Later that day, DHS stated that they let hospice representative know via text messages. . LPA Ascencio received text message screenshots dated April 25th, 2022 confirming a conversation between DHS and Hospice representative stating that the day hospice was notified of bed sore was April 13th. DHS also added that they did not call R1’s representative.
Continued on LIC 9099 - C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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-20220504151158
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: 05/17/2022
NARRATIVE
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It was my mistake we did not call. We assumed hospice was going to let family know but it is our responsibility to let family know of any changes in condition. We dropped the ball on that. On 05/05/2022, starting at around 3:10 p.m., LPA Ascencio reviewed the Observation Notes dated from April and May 2022, and revealed that on April 13th, 2022, staff notified hospice nurse of wound in coccyx. There was another entry, dated April 23rd, 2022 that stated that the family member was very upset they were unaware of R1’s wound. LPA Ascencio questioned DHS regarding the entry on the Observation Notes, DHS stated that is the day we let family know because they saw the wound on R1’s bottom. DHS added, yes, it was about ten (10) days before we talked to family regarding the open sore.

Based on record review and interviews, the allegation of facility staff did not notify the resident’s authorized representative of a change in the resident’s condition is deemed Substantiated at this time.

1 citation were issued during today’s visit. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.



Copy of the report and appeal rights provided to Admin via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220504151158
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited
CCR
87705(b)(1)
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87705 Care of Persons with Dementia (b)(1)In addition to the requirements as specified...plan of operation shall address the needs of residents with dementia, including: Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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Admin stated they will conduct facility training on mandated reporting by outside agency. Admin will collect all training material and attendees and send to LPA via email.
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This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as facility staff did not notify family member of R1’s change in condition which poses an immediate health, safety and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3