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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:32:55 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
07/07/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210707125403
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: 46DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mike O'Neil, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff inappropriately spoke to (and in front of) residents in care.
Staff did not obtain medication for resident on a timely basis.
Staff allowed resident to have access to medications.
Facility staff are not properly trained.
Facility did not provide a comfortable environment for residents (inappropriate load music played by staff).
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the remaining complaint allegations. LPA met with Administrator Mike O’Neil and explained the purpose of the visit.

LPA Rosales conducted the initial complaint investigation on 07/12/2021 at 3:30 PM – 7:21 PM, LPA Rosales interviewed staff at 3:30 PM, toured the facility with the Administrator, reviewed random resident medications/records, took 2 photographs, and obtained copies of pertinent documents. LPA Rosales conducted interviews on 04/09/2021 with Administrator at 8:34 AM, on 06/07/2021 at 2:21 PM with staff, on 06/15/2021 at 11:52 AM, 12:09 PM, and 12:53 PM with staff, on 07/12/2021 at 10:01 AM with witness, on 08/24/2021 at 9:22 AM with staff, on 10/04/2021 at 2:15 pm with staff, on 03/09/2022 at 9:22 AM and 9:37 AM with staff and on 03/10/2022 at 2:00 PM and 2:28 PM with staff. LPA De Leon reviewed interviews and documents on 04/30/2021 and requested additional documents on 05/01/2023, recieved and reviewed on 05/03/2023.

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: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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 8
Control Number 29-AS-20210707125403
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: 05/03/2023
NARRATIVE
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On the allegation: Staff inappropriately spoke to (and in front of) residents in care. LPA Rosales interviewed Witness 1(W1) which revealed that R1 told R1’s doctor that it would be nice if staff would stop speaking Spanish in front of R1.
Administrator’s interview revealed Administrator did have a complaint from a male staff indicating that S10 was speaking inappropriately in Spanish to other staff. Administrator stated that they counseled S10 on 2/18/21 and again on 3/24/21. Administrator stated that they have asked S10 to eliminate the use of Spanish in the facility and if this incident were to occur again S10 will be terminated. Administrator is not aware of any staff using curse words around any residents.
S2’s interview revealed S2 has heard staff 4 (S4) used inappropriate language regarding R5 when venting to the Nurse and other staff, S4 did not say it directly to R5 and S2 does not think R5 heard, S2 heard S4 cuss at R5 directly, R5 is in the Topa Top building and S2 has gone to the Director about the cussing and language used by S4 before. S2 interviews also revealed that there are so many employees that are fed up and would like to leave, things are terrible and people are lying, prior staff S10 got written up and sent to work in a different building for a week but then was allowed back, S10 was making comments about R3’s genitals, S10 would also cuss around R3, S2 said that there were 2 staff that sent emails to the Administrator Therese about it, the emails would be in the employees file.
S3’s interview revealed S10 had a mouth, S3 heard S10 talk about R3’s privates, S3 spoke with S10 about it, S10 would talk nasty to a staff in the breakroom, there were no residents around at the time, S3 would tell S10 not to talk like that, S3 sent an email to Administrator about S10, S10 was let go about a month after that.
S7’s interview revealed that one time one of the staff called resident 5 (R5) a pig, S7 does not remember in what context, S7 just remembers the staff referring to R5 as a pig, S7 only heard the staff call the R5 a pig the one time only and that staff 5 (S5) heard it as well, S7 does not think that R5 heard the staff call R5 a pig.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
NARRATIVE
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S4’s interview revealed R5 has a tendency to get in S4’s face, S4 told R5 to get out of S4’s face and R5 lashed back and said cuss words at S4, S4 said R5 is very nasty, S4 does not think that S4 told R5 anything back other than it was inappropriate for R5 to say that, S4 said S4 just walked away, S4 has probably calle R5 a pig to S4’s self before, it was probably the time that R5 took R4’s peanut butter, S4 does not know if anyone else heard S4 say it, it all started with the lights in the library when S4 was in their charting, S4 left the lights on and R5 told S4 it was wasteful, S4 told R5 that the lights were automatic. S4 denied ever calling R5 cuss words, things have been alot better with S4 and R5, and S4 has learned to be alot kinder to R5. S4’s interview also revealed S4 observed S10 tell R3 inappropriate sexual things, S4 had observed S10 cursing around all the residents, S10 was moved out of that building for 2 weeks to the Matilija building and then S10 was put back in the Topa Topa building.
S5’s interview revealed S10 would make inappropriate comments to R3, S10 would put music on the residents tv and would dance, S10 would talk about R3’s genitalia, S5 never heard S10 curse around the residents.
S6’s interview revealed back in December 2021 S6 knew that there was a verbal exchange between S4 and R5, S6 had to do something about it, do not recall what S4 said as S6 did not document it but it was something that S4 should not have said, S6 said R5 told S6 this.
S10’s interview revealed R5 would be targeted and bullied by S4, S3 and S1, R5 would complain to Therese (Administrator) and Administrator really did not get involved, S4 would say "what a pig, that's disgusting.", it got to a point that R5 would not stay and socialize in the dining room, Administrator swept it under the rug, S5, S7 S2 and other staff all observed it, Administrator received emails from R5 about the rude comments S4 was making and Administrator just brushed it under the carpet. In S10’s interview S10 thinks that a bad word would slip out when S10 would talk with staff about S10’s private life, S10 had gotten a write up about it, S10 did not say anything inappropriate or sexual to R5.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
NARRATIVE
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LPA De Leon’s record/documents reviewed revealed S10 had a write up on 02/18/2021 for allegations of sexual harassment towards a resident and a staff member and attached to the write-ups is four emails from other staff reporting the incidents to the Administrator. On 04/16/2021 S10 had another write-up for stealing a resident’s drinks and S10 was eventually terminated on 04/18/2021. LPA reviewed additional records that S4 had 3 write-ups’ on 04/18/2021 for a resident’s rights violation, on 05/25/2022 for medication error, and on 05/31/2022 for another resident rights violation attached to those write ups were 9 emails from other staff complaining about S4 with residents and other staff members, and S4 was terminated from employment. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Staff did not obtain medication for resident on a timely basis. LPA Rosales interviewed S1 which revealed S1 is the Nurse on staff and S1 was not able to give R2’s 4 pm Pantoprazole as S1 did not have a refill, S1 was not able to give R3’s Colace today as S1 did not have a refill. LPA Rosales interviewed S5 which revealed one-time S1 did not order R6’s medications last month and when S1 went on vacation, R6 ran out of medication that keeps R6 calm and S5 had to deal with it the whole week, R6 has bad behaviors, R6 will scream, yell and slam R6’s room door. LPA De Leon interviewed current Administrator Mike O’Neil on 05/03/2023 at 12:30 PM regarding the facility’s procedures to refill residents’ medication and according to Administrator centrally stored medication would be refilled by request of facility staff if the resident used the facility recommended pharmacy the staff would call and order the refills, if the resident used own pharmacy the staff would contact the responsible party of the residents before running out of medication to get refills, and if the residents medication had no refills left the facility would contact the residents doctor before running out of medication and request another prescription order to refill. Based on the evidence this allegation is deemed Substantiated at this time.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
NARRATIVE
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On the allegation: Staff allowed resident to have access to medications. LPA Rosales interviewed W1 which revealed W1 found Calcium and Vit D pocket cards with partial medication intact dated March 2021 in R1’s room bookshelf, this on first visit after COVID visitation in building was allowed during first week of May, W1 discussed issue with S1 of concern and returned medication to S1, on 5/20/21 R6’s 3 medication boards were found in R1’s dresser drawer: Tylenol (filled 4/1/21), Calcium (3/10/21), empty Aldenronate package (4/1/21) with a note written on label by R6 “ Time?”, as well as a box of fortoflora probiotic prescription by vet for R1’s dog with 16 packets on R6’s bathroom sink. W1 emailed Administrator that day with both W1’s findings and concerns for medication safety as well as question if R6 is receiving the medications R6’s physician had ordered? W1 returned medications to administrator the next day and submitted a photo to CCL with the bubble packs of medications found in R1’s room. Based on the evidence this allegation is deemed Substantiated at this time.
On the allegation: Facility staff are not properly trained. LPA requested documents on 05/01/2023 for staff medication and dementia training from 2020 and 2021. LPA received and reviewed facility training records on 05/03/2023 several staff did not have medication or dementia training for the year 2021. The records reviewed revealed the facility hired 41 staff in 2021, 3 staff were terminated in 2021, 24 staff quit in 2021 and 2 staff left employment in 2021 reasons unknown. The facility had 14 medication technicians in 2021 that would have required initial medications training of 24 hours or annual medication training of 8 hours, 5 staff completed initial 24 hour medication training in 2021, and 5 staff attended 1 hour of medication training on 02/16/2021. Dementia training requirements are 12 hours initial training and 8 hours of annual training records provided and reviewed revealed on 01/15/2021 12 staff attended a 1-hour Dementia-Covid training, on 02/05/2021 13 staff took a 50 minute dementia-language skill training, and on 10/23/2021 18 staff took a 50 minute to 1 hour training on types of dementia for a total of 3 hours of dementia training for 2021. Based on the evidence the facility did not provide staff with the required initial or annual training therefore the allegation is Substantiated at this time.
Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
NARRATIVE
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On the allegation: Facility did not provide a comfortable environment for residents (inappropriate load music played by staff). LPA Rosales interviewed W1 which revealed on 6/30/21 around 1:45 pm W1 picked up R1 for a dentist appointment and staff were playing rapping music and techno music on dining room tv quite loudly, obviously playing what the staff like as no 70–80-year-old would be listening to that in their own homes. LPA interview with S5 revealed that S10 would put music on the residents tv and would dance. LPA De Leon reviewed records/documents and S10 has a writeup with an email dated 03/23/2021 at 11:28 AM from S2 reporting to the Administrator that S2 feels S10’s volume and quality of music being played should always be taken in consideration since this is the home of the residents, playing music which is appropriate for the residents liking and at a respectable level, this topic has been brought up at a least one resident council meeting, multiple managers meetings and on an in-service meeting, yet S2 sees and hears the issue continuing constantly, S2 found themselves in an embarrassing situation yesterday of having inappropriate music being played at loud levels while S2 was with family members visiting their loved ones, S2 does not think lyrics, “I’m bringing sexy back, you mother F’ers best know how to act!” are words family members or residents are pleased at hearing which then leads to the staff that are still speaking Spanish and in an attempt to remedy the situation S2 was met with attitudes from S10 and S5. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies issued, 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: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87468.1(a)(3)
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(a)...(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature,… This requirement was not met as evidenced by:
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Administrator agreed to train all staff on personal rights and mandated reporting, incident and complaint reporting and send proof to CCL.
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Based on Interviews/Records review the licensee did not comply with the regulation above R5 was being cussed at, R3 was being sexually harassed which possess an immediate Personal Rights risk to residents in care.
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Type A
05/05/2023
Section Cited
CCR
87465(h)(1)(B)
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(h)...(1)...(B)Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by:
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Administrator agreed to train caregivers and medications technicians in regulation 87465 and facility policy and procedures for all Centrally Stored Medications and refills, provide proof of training to CCL.
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Based on interviews/records review the licensee did not comply with the regulation above R1’s medications were left in room/drawers in R1’s room and medications for residents were not refilled timely which poses a immediate health and safety risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20210707125403
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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2023
Section Cited
CCR
87706(a)(2)
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(a)(2)...complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. This requirement was not met as evidenced by:
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Administrator agreed to have all staff take dementia trianing and all staff that handle and help administer medications re-trained on Medications,
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Based on record review the licensee did not comply with the regulation above as staff did not have required dementia and medications training which poses a potential health, safety, and personal rights risk to residents in care.
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CCL Medication Guide for RCFE, Mandated Reporter, and facility policy and procedures on medications set out in the facility plan of operations and provide proof of training to CCL.
Type B
05/10/2023
Section Cited
CCR
87468.1(a)(2)
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(a)...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator agreed to hold personal rights training for all facility staff and send proof of training and an up to date LIC 500 to CCL
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Based on Interviews/record review the Licensee did not comply with the regulation above S10 played load inappropriate music on the resident’s television on multiple occasions which poses a potential personal rights risk to residents 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8