567609954-5-24-2023-29-AS-KBUY-CSD2FH-20230531172133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:07:42 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
09/27/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20210927103652

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: 46	DATE:	05/24/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mike O'Neil, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Insufficient staffing to meet residents needs
Resident not being provided medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Mike O’Neil Administrator and explained the purpose of the visit.

LPA Rosales conducted the initial 10-day complaint visit on 10/05/2021 at 11:06 AM – 4:45 PM, toured facility, obtained pertinent documents and interviewed staff at 12:08 PM, 12:42 PM, 1:17 PM, 1:46 PM, 1:57 PM, 2:21 PM and interviewed residents at 2:48 PM, 2:53 PM, 2:58 PM, and 3:08 PM. LPA Rosales interviewed staff on 10/04/201 at 2:15pm. LPA Acenscio interviewed staff and witnesses on 08/02/2021. LPA reviewed interviews and documents from this complaint on 04/30/2023, 05/01/2023 and 05/02/2023.

On the allegation: Insufficient staffing to meet residents needs. LPA De Leon reviewed staff schedules during 08/29/2021 - 10/02/2021 which revealed the facility had three buildings on the property called Topa Topa, Matilija, and Maricopa with a total resident census of 38. Topa Topa building was the memory care building, and the census was 18 on the facility report dated 10/05/2021.
Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 6

Control Number 29-AS-20210927103652

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: 05/24/2023

NARRATIVE

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The Topa Topa Building was scheduled with 3 guides in the AM, 3 guides in the PM, and 1 guide on the NOC as well as a 1 medication-technician Lead Guide (MT) to service all 3 buildings on each shift. The schedules reviewed showed that on several occasions during the above dates the Topa Topa building worked short staffed with only 1-2 Guides; on 08/29/2021 2-AM Guides and 2-PM Guides, on 08/31/2021 2-PM Guides, 09/03/2021 2-PM Guides, 09/04/2021 2-AM Guides and 0-NOC Guides leaving the Lead Guide to cover the building and no MT to cover the 3 buildings, on 09/5/2021 2-PM Guides, 09/07/2021 2-PM Guides, 09/09/2021 2-PM Guides, 09/11/21 2-AM Guides and 1-PM Guide, No Lead Guide PM shift leaving no MT to cover all 3 buildings, on 09/12/21 1-PM Guide, on 09/13/2021 2-AM Guides, 09/16/21 2-PM Guides, 09/18/21 1-PM Guide, on 09/19/2021 2-PM Guides, 09/20/21 2-PM Guides, 09/24/21 2-PM Guides, on 09/25/2021 2 AM Guides and 2-PM Guides, on 09/26/2021 2-AM Guides and 1 PM Guide, 09/27/2021 2-PM Guides, on 09/28/2021 1-PM Guide, on 09/29/2021 1-PM Guide, and on 10/02/2021 2-PM Guides.

The interview with staff 1(S1) revealed the kitchen person prepares the meals for the residents in the Topa Topa building and the Matilija building, cooks, oversees the residents in the dining room, cleans the kitchen and dining room and the other Guides on shift will shower the residents, help them get dressed, clean their rooms, do their beds, and wash their clothes. 7 residents need assistance with showers, 3 residents can shower without assistance, and the other residents have Home Health aides that shower them. If there are only 2 Guides staff do all showers, beds, maybe not the deep cleaning of rooms, and/or laundry, and there are no housekeeping staff. S1 stated that if staff do not do a shower on Monday, they will do it on Tuesday.
Staff 2 (S2) interview revealed all residents needs assistance with toileting, S2 does patient care, cooking for the Topa Topa and Matilija, kitchen clean up after each meal, check on the residents, make sure that the trashes are taken out, make sure that the residents are dry, shower the residents on certain days, Hospice will shower 5 residents and 4 residents do their own showers. On certain days staff do deep cleaning, once a week the resident rooms are deep cleaned, showers, toilets, and sinks scrubbed, sheets washed, dusting, mopping, vacuuming, and new sheets put on beds. When it is only 2-Guides on duty staff are unable to do cleaning, when it is too chaotic staff may miss a shower, but staff will get it done the next day, can't get it all done with two staff and during the PM shift there is only 1 staff sometimes.
Staff 3 (S3) interview revealed S3 is not scheduled to cook, S3 assists residents with dressing, toileting, if resident is scheduled for shower that day S3 will shower the resident. S3 stated that on Mondays S3 does 3 residents showers, there are normally 3-Guides on duty, 1 staff can do the showers and 1 staff will clean rooms and change bedding if deep cleaning that day, 1 in the kitchen preparing and cooking, on down time with cooking staff will clean the dining room, and if there is a resident in the dining room needing assistance staff will assist the resident. NOC shift does the laundry and AM will put away the next day.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20210927103652

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: 05/24/2023

NARRATIVE

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Resident care comes before cleaning. Staff 6 (S6) interview revealed on days when they are short-staffed staff do not do full cooking of meals maybe frozen lasagna or frozen enchiladas, Supervisors will have the morning staff stay late or the NOC shift come in early to help with coverage, S6 sometimes hears that showering doesn't get achieved so staff will do them the next day, S6 is not aware of any toileting issues, each day for each shift staff will have 2 to 4 rooms to clean, if staff cannot get it done staff can do it the next day, S6 stated that in the Topa Topa building it is staffed with 3 care staff.

Resident 5 (R5’s) interview revealed that staff do help them if they ask for help, R5 pushes pendant quite often and it doesn't work, R5 can go 4 or 5 days without a bath if R5 does not ask and even if R5 does ask, on 10/04/2021 R5 woke up at 5 am and hit R5’s pendant and waited and waited and nobody came, R5 looked out R5’s door and saw no one was around, R5 have told staff that R5 likes to eat seafood and R5 cannot remember when R5 has had any seafood, R5 was not aware of a resident not getting timely medical attention, usually there is 1 caregiver on the NOC shift at night and R5 could not find them.

Witness 3’s (W3) interview revealed the facility was short staffed all the time and the residents’ needs were not being provided. If you needed help it was hard to find a staff on the floor to help you. The staff called Guides were to provide resident care, cook and clean the building. The Topa Topa building was memory care residents, and the staff did not have the knowledge to care for the residents. The meals provided to the residents were not edible. W3 would bring in meals even though W3 paid the facility for 3 meals a day. The facility never provided snacks to the residents. The facility was not following doctor prescribed low sodium diet for Resident 6 (R6) and they did not have staff that had the knowledge to prepare and cook meals for the R6. R6 fell on a few different occasions were R6 clearly needed medical care and it was not provided. W3 stated W3 was not notified of several incidents with R6. Medications were an issue several times staff did not order for it to arrive before residents were out of medications. There was another resident that was out of control and the staff did not know how to handle the resident. The facility did not have enough staff on the floor to take care of the residents and their needs and the ones that were good would quit because of all the problems going on at the facility. R6 had bed sores from not being rotated while in bed after a fall and eventually declined and passed away at the facility on hospice services.

Based on the evidence the allegation is deemed Substantiated at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20210927103652

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: 05/24/2023

NARRATIVE

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On the allegation: Resident not being provided medical attention in a timely manner. LPA De Leon reviewed the staff notes provided by facility for R1 from 11/17/2020 – 10/01/2021 had indicated R1 had fallen 25 times, on 4 of those times staff called 911 and R1 was taken to the hospital only 2 of those times Community Care Licensing received an incident report for R1. After a fall on 11/08/2020 R1 complained of knee pain and continued to complain of knee pain later that day then on 11/11/2020 R1 stated again R1’s knee hurt R1 was not taken to be seen until 11/17/2020 when 911 was called for R1 falling and hitting R1’s head with a laceration above eye, knee pain was never addressed. On 07/27/2021 R1 had a fall and expressed feet and knee pain, R1 was given a PRN for the pain. On 08/17/2021 around 7:56 AM R1 had a fall, R1 hit head facility staff had a Nurse Practitioner (NP) come to the facility for a visit at 8:46 AM whom encouraged compression stockings and encouraged fluid then at 1:32 PM R1 was assisted to floor when toileting, then at 2:40 PM R1 had another fall as the evening went on around 8:00 PM, R1 was unable to feed self then around 10:03 PM it was noted that R1 was unable to stand or walk. On 08/19/2021 LVN made a note that R1’s doctor was called, and X-rays were ordered for the pelvis hip area to rule out any hairline fractures, no notes were made if these x-rays were completed or revealed any issues with R1. On 08/23/2021 R1 had a fall no injury was noted and at 10:14 PM it was noted that R1 was found on the floor around 7:45 PM staff noticed R1’s legs and feet were swollen. On 08/24/2021 at 9:08 PM R1 was found kneeling on the floor with no injury R1 was toileted with a very strong smell of urine and an increase frequency of urination with no complaints of pain or injury but later that day R1 complained of shoulder and back pain. Same day at 9:12 PM it was noted by staff that R1 was having a hard time walking and complaining of back and shoulder pain MT and LVN was made aware and LVN stated LVN would contact R1’s doctor tomorrow. On 08/25/2021 at 3:43 PM it was noted by staff that R1 had a strong urine smell when toileting then at 9:47 PM it was noted that R1 was agitated, restless, strong odor and dark urine, both legs extremely swollen and rash by ankles looks like beginning of Cellulitis. On 08/26/2021 Hospice came out to evaluate and admit R1 to hospice, also the facility had a visit by Podiatrist who seen R1 that day. On 08/27/2021 8:30 AM R1 was noted to have an NP visit noting suspected TIA’s and possible seizures then at 4:00 PM had a Hospice Nurse visit who notified doctor of pain, pain medication ordered for lower extremities and wrap for lower extremities. On 08/27/2021 R1 had a fall in the evening at 6:30 PM which required a 2 person assist and Hospice was notified by LVN, a nurse will visit tomorrow between 8am-10am, no note was made for 08/28/2021 of any visits to see R1. On 08/30/2021 at 10:55 AM R1 had another fall paramedics came to evaluate but R1 was not transported, Hospice Nurse visited around 3:00 PM and provided an order for a bed pad alarm, Pt to use wheelchair and nonskid shoes, discontinued some medications, pressure pad alarm needed when in bed, chair or wheelchair to alert staff to help R1 in preventing falls, then at 9:21 PM it was noted that at 6:30 PM R1 was found on floor with no injury.
Staff 6’s (S6) interview revealed R1 was found on the floor on R1’s knees various times. Sometimes staff would find R1, it was clear that R1 did not hit R1’s head, therefore not needing to go to hospital, R1 had slips from the couch or the bed onto the floor so there wasn't a need for an incident report, due to one of the falls, resident has had pain in groin area.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20210927103652

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: 05/24/2023

NARRATIVE

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Witness 1 (W1’s) interview revealed W1 did not receive a call from facility regarding R1’s falls that had happened on 7/22,7/26 and 7/27, W1 was aware of a 7/17/2021 fall with R1, due to finding out from a hospital bill that arrived at W1’s home for R1. W1 had to contact the facility regarding the fall to find out what happened with R1 on 07/17/2021.

Witness 2 (W2’s) interview revealed W2 had not received any calls regarding the falls that had happened to R1 on 7/22,7/26 and 7/27. The only call W2 received was on 7/17/2021, but W2 has not received any afterwards. W2 would have liked for R1 to be sent out for evaluation due to frequency of falls R1 was having.

Witness 3 (W3’s) interview revealed R6 had falls that were not report and R6 did need medical attention for one of those falls but was not sent out for medical attention. W3 learned about the fall from a staff that told W3 R6 had a fall and was not sent out to the hospital but clearly needed medical attention, R1 had pain and was unable to walk after a fall, the fall was not reported to W3 by the facility.

Based on the evidence the allegation is Substantiated at this time.

Exit interview completed, deficiencies cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20210927103652

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: 05/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/26/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care… Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering…This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review residents needs and based on those residents needs employ enough competent staff for personal assistance, care, cooking, house cleaning and laundering as well as bring all staff up to date on annual training requirements to meet the residents needs of care in all areas.
	8 9 10 11 12 13 14	Based on interviews and records review the licensee did not comply with the regulations above the facility did not have sufficient or competent staffing to me the resident’s needs, which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type A 05/26/2023 Section Cited CCR 87468.1(b)(8)	1 2 3 4 5 6 7	(b)... (8)Deny or restrict medical or nonmedical care that is appropriate to a resident’s organs and bodily needs, or provide medical or nonmedical care to the resident...demeans the resident’s dignity or causes avoidable discomfort. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review and train in personal rights, dementia, reporting, mandated reporting, fall procedures, emergency procedures for all staff that handle resident’s care and provide an up to date LIC 500 and proof of training to CCL.
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not comply with the regulation above Residents were restricted on the care provided when residents were experiencing pain after falls and medical attention was not provided timely which poses an immediate Health, Safety and Personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC9099 (FAS) - (06/04)

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