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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 04/17/2023
Date Signed: 04/17/2023 05:01:36 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
05/12/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210512093307
FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR:BROWN, MARY THERESAFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:72CENSUS: 47DATE:
04/17/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Mike O'NeilTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not provide timely medical attention for a resident in care
Staff are not adequately meeting a resident's needs
Resident has significant weight loss
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Administrator Mike O’Neil at 10:50 AM and explained the purpose of the visit.

LPA Rosales conducted the initial complaint visit on 05/24/2021 at 10:50 AM, toured facility, reviewed resident’s records, and interviewed staff at 11:48 AM, 12:05 PM, and 12:14 PM. LPA’s Rosales and Guzman-Chavez and conducted a subsequent complaint to the facility on 06/15/2021 at 10:04 AM, toured facility, interviewed resident at 1:21 PM, interviewed staff at 11:45 AM, 12:09 PM, 1:01 PM, and 2:06 PM. LPA Rosales interviewed witness on 05/18/2021 at 1:25 PM. LPA Rosales interviewed staff on 06/18/2021 at 9:22 AM.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
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 7
Control Number 29-AS-20210512093307
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: 04/17/2023
NARRATIVE
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 LPA Rosales interviewed staff and Administrator on 04/30/2021 at 10:39 AM, 12:07 PM, and 2:23 PM. LPA Rosales interviewed staff on 06/04/2021 at 2:21 PM and on 06/07/2021 at 4:14 PM. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed staff on 04/16/2023 at 11:45 AM and 11:59 AM. LPA Rosales received documentation on 05/18/2021, 5/24/2021, and 08/26/2021. LPA De Leon reviewed documentation from 04/12/2023 – 04/17/2023. LPA De Leon requested additional documentation on 04/17/2023.


On the allegation: Staff did not seek timely medical attention for resident. LPA’s Rosales, Ascensio and De Leon interviewed a total of 18 people during the investigation. LPA Rosales interview with Administrator stated that R1 had an unusual condition. R1 was experiencing pain. Administrator stated that at one-point R1 rolled out of bed and immediately staff sent R1 out for Xray, R1 had verbalized pain in R1’s hip area, x-rays were all fine, the resident then experienced a change in condition. S5 interview revealed R1 had 7 weeks previous to an incident with R1 on 05/19/2021 R1 had fallen and had a fracture on R1’s hip joint which is why R1 needed to stay in bed or in a chair, R1’s doctor said R1 didn’t need surgery. S5 said Staff have been using a lift because R1 cannot weight bare. S5 admits S5 did not call R1’s family to let them know about the change in condition. Staff interviews revealed R1 had a fall on the NOC Shift at some time during the early am of 04/13/2021. Staff Notes were written in the system by S12, and the entry could not be produced by the Administrator. R1 was not sent out after the slip or fall out of bed on 04/13/2021 early am, notes produced by the facility showed entry on R1 by Staff on 04/13/2021 at 1:40 PM very week today, had to use another resident’s wheelchair to transfer, right side of face was swollen and has a bruise on his right elbow. Had to have assistance today for both meals with feeding, in bed laying down. A later entry on R1 by another staff dated 04/13/2021 10:22 PM, R1 had difficulty with standing, needed a two person assist, complained of pain when moving, ate 100% of dinner, wanted to get up and walk, took a few steps with difficulty unable to take a step with left leg, two guides assisted with R1 wanting to walk, no complaints of pain at time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20210512093307
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: 04/17/2023
NARRATIVE
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Another note entry for R1 on 04/14/2021 at 3:33 PM states Tomorrow I will be taking resident for X-ray of his back and left hip, W1 reports R1 has had problems with R1’s back in the past. R1’s doctor wants to check and make sure then will go from there. On 04/15/2021 at 1:14pm R1 has an entry stating Took Resident this morning for X-Rays of his left hip and lower back has metal in it from past surgeries, vertebra unfused together waiting to hear from R1’s doctor. Entries go on from there dated 04/15/2021 stating R1 was very lethargic, dead weight, was in the wheelchair, very weak, was unable to get up on own. On 04/16/2021 at 1:37 PM other notes on R1 stating very week, very sluggish, put back in bed, took 3 to transfer, sent out to the ER after lunch has not returned. R1 returned to the facility on 04/16/2021 with UTI and prostate infection. R1’s slips out of bed, fall happened on 04/13/2023 around 5 AM, R1 was not sent out for X-Ray until the morning of 04/15/2021 and R1 was not sent out to the ER until 04/16/2021 after lunch. Based on the evidence this allegation is deemed Substantiated at this time. Deficiency has been addressed for this allegation on Complaint # 29-AS-20210422132534 regarding R1.

On the allegation: Staff are not adequately meeting a resident's needs. LPA’s interviewed staff which revealed one staff stated the facility was very short-staffed during April of 2021. One staff stated they were left alone without help on a shift and had a resident refusing medication with out-of-control behaviors staff had to call family and paramedics then turned in their two weeks’ notice after that incident. One staff stated one night a resident fell and staff had to leave one building with no staff to go over to help another staff in the other building so the residents were left alone. One staff stated there is one Medication Technician on NOC shift for 3 buildings and only 1 staff in each building. One staff stated often there is not enough staffing. A resident interview stated at times they do not get showered sometimes for 4-5 days even when they have asked to be showered, the NOC shift only has one staff, and they were not answering the pendant press and the resident went out the door and could not find anyone on shift. LPA De Leon reviewed the facility records for staff schedules during the month of April 2021.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210512093307
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: 04/17/2023
NARRATIVE
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 The facility schedule is for two buildings the Maricopa and the Topa Topa buildings are staffed with 1 AM Lead staff is scheduled, and 3 Guides staff are scheduled, on the PM 1 Lead is scheduled and 3 guides are scheduled, the NOC shift has 1 lead and 1 Guide is scheduled, the lead guides scheduled are the lead for both buildings and the guides are in each building. On 80 occasions during the April 1, 2021, to May 1, 2021, schedule, shifts were open, staff called out, staff wasn’t scheduled, AM, PM, and NOC staffed either worked later, came in earlier, or covered additional shifts, and LVN covered some shifts. On the NOC shift schedule for 04/11/2021 and 04/12/2021 1 staff was scheduled as lead for 2 buildings and only 1 staff was scheduled in the Topa Topa building, no guide was scheduled in the Maricopa building so the lead would not have been able to leave the Maricopa building on those nights to help the guide in the Topa Topa building without leaving the Maricopa building without staff. Several staff stated notes were put into the system by the NOC shift around the date of 04/12/2023 shift that in the early am resident (R1) fell or rolled out of bed and staff were instructed to put him back in bed and LVN would check on resident. On those dated the facility was short staffed based on the schedules. Based on the evidence this allegation is deemed Substantiated at this time. Deficiency has been addressed for this allegation on Complaint # 29-AS-20210422132534 regarding R1.

On the allegation: Resident has significant weight loss. LPA De Leon reviewed Facility records on Resident 1 (R1) which showed: Upon admission to the facility R1’s LIC 602 physicians report stated R1’s weight as 196 lbs. on 12/09/2019 exam, and weight records, date 5/14/21 at 1:07 pm Value 190 lls., date 3/15/21 at 9:00 am Value 192 lbs., date 2/17/21 at 9:00 am Value 189.4 lbs., date 1/16/21 at 3:44 pm Value 150 lbs., date 12/14/20 at 10:38 am Value 194 lbs., Recorded date 11/18/20 at 10:19 am Value 186.9 lbs. There is no documented weight record for April 2021. Staff interviews revealed that R1 was given a purred diet, had noticeable weight loss and W1 brought in a doctor’s order for R1 to go back to a regular diet. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, two deficiencies cited on prior Complaint # 29-AS-20210422132534, Copy of report and appeal rights printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210512093307
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: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2023
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by:
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Administrator agreed to read/review regulation 87466 and train staff on the policies and procedures for resident care and documentation, as well
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Based on interviews/record review the licensee did not comply with the regulation above R1’s weight gains, losses or physical health conditions were not being documented and brought to R1’s responsible party which poses potential health, safety and personal rights risk to residents in care.
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as procedures to follow when reporting changes in resident condition and needs. Send proof of staff training and up to date LIC 500 to CCL.
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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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/12/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210512093307

FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR:BROWN, MARY THERESAFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:72CENSUS: 47DATE:
04/17/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator Mike O'NeilTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not take a resident to medical appointment timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Mike O'Neil at 10:50 AM and explained the purpose of the visit.

LPA Rosales conducted the initial complaint visit on 05/24/2021 at 10:50 AM, toured facility, reviewed resident’s records, and interviewed staff at 11:48 AM, 12:05 PM, and 12:14 PM. LPA’s Rosales and Guzman-Chavez and conducted a subsequent complaint to the facility on 06/15/2021 at 10:04 AM, toured facility, interviewed resident at 1:21 PM, interviewed staff at 11:45 AM, 12:09 PM, 1:01 PM, and 2:06 PM. LPA Rosales interviewed witness on 05/18/2021 at 1:25 PM. LPA Rosales interviewed staff on 06/18/2021 at 9:22 AM. LPA Rosales interviewed staff and Administrator on 04/30/2021 at 10:39 AM, 12:07 PM, and 2:23 PM.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210512093307
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: 04/17/2023
NARRATIVE
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 LPA Rosales interviewed staff on 06/04/2021 at 2:21 PM and on 06/07/2021 at 4:14 PM. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed staff on 04/16/2023 at 11:45 AM and 11:59 AM. LPA Rosales received documentation on 05/18/2021, 5/24/2021, and 08/26/2021. LPA De Leon reviewed documentation from 04/12/2023 – 04/17/2023. LPA De Leon requested additional documentation on 04/17/2023.

On the allegation: Staff did not take a resident to medical appointment timely. LPA interviewed Witness 1 (W1) which revealed resident 1 (R1) had a medical appointment and W1 had to call the facility as Facility Staff were supposed to take R1 to R1’s appointment and meet W1 there. W1 stated that when W1 called the facility staff was still there and the staff was 20 minutes late to the appointment, R1’s doctor was still able to accommodate the appointment and R1 was seen by the doctor therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7