567609954-5-24-2023-29-AS-KBUY-CSCPVK-20230531113915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:24:07 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
11/15/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20211115100401

FACILITY NAME:	ARTESIAN OF OJAI, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR:	MICHAEL O'NEILL		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:	Michael O'Neill, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Insufficient staffing to meet residents needs.
Staff mishandled resident medications.
Incident was not reported to the authorized representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon made a subsequent complaint visit to the facility above to deliver final findings on the complaint investigation. LPA met with Mike O’Neil, Administrator and explained purpose of the visit.

LPA Rosales conducted the initial complaint visit on 11/22/2021 from 10:09 AM – 3:10 PM, LPA toured the facility with the Administrator, interviewed random residents at 1:58 PM, 2:01 PM, 2:04 PM, 2:08 PM and staff at 1:11 PM, 1:28 PM, 1:37 PM, and 2:12 PM and obtained copies of pertinent documents. LPA De Leon reviewed complaint, records and interviews on 05/17/2023 and 05/18/2023. LPA De Leon requested additional records from facility 05/18/2023.

On the allegation: Insufficient staffing to meet residents needs. LPA De Leon reviewed facility staffing schedules from 08/29/2021 – 11/06/2021 which revealed the facility had three buildings on the property called Matilija, Topa Topa, and Maricopa with a total resident census of 37.
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 8

Control Number 29-AS-20211115100401

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 schedule shows the Matilija building was normally scheduled with 1 Guide and 1 Lead Guide on the AM, PM and NOC shifts from 08/29/2021 till 09/27/2021. The Lead Guide is the medication-technician (MT) that does the medications for all 3 buildings on each shift. The records show on 08/29/2021 there was no Lead Guide on the PM and NOC shift so the Wellness Care Manager came in to work a shift of 2:00 PM – 7:00 PM for coverage leaving no one at the facility to do medications after 7 PM, on 09/05/2021 the AM shift did not have a Lead Guide scheduled but their was a manger on duty to distribute medications, on 09/06/2021 no Lead Guide was scheduled on the PM shift, on 09/11/2021 no Lead Guide on NOC shift scheduled, on 09/15/2021 no Lead Guide scheduled for the NOC shift, on 09/17/2021 no Lead Guide scheduled, on 09/25/2021 no Lead Guide scheduled for the NOC shift, on 09/26/2021 no Lead Guide scheduled on NOC, on 09/27/2021 no Guide scheduled on the PM shift. On 09/28/2021 the normal staffing schedule now showed 2 Guides on AM/PM and 1 Guide on NOC with 1 Lead Guide for all 3 facilities each shift. The Matilija schedule showed on 10/02/2021 only 1 AM Guide scheduled, on 10/03/2021 only 1 AM Guide and no Lead Guide scheduled on the NOC shift, on 10/04/2021 only 1 AM & PM Guide scheduled, on 10/07/2021 on 1 AM Guide scheduled, on 10/09/2021 only 1 AM & PM Guide was scheduled and No Lead Guides scheduled on the NOC shift, on 10/10/2021 only 1 AM Guide scheduled and no Lead Guide scheduled on the PM shift, on 10/11/2021 only 1 AM Guide scheduled, on 10/14/2021 only 1 AM Guide scheduled, on 10/16/2021 only 1 AM Guide scheduled, on 10/17/2021 only 1 AM/PM Guide scheduled and no Lead Guide scheduled for the PM/NOC with a Manager only working 8AM-5PM, on 10/18/2021 only 1 PM Guide scheduled, on 10/19/2021 only 1 PM Guide scheduled, on 10/21/2021 only 1 AM Guide scheduled, on 10/22/2021 only 1 PM Guide scheduled and no Guide scheduled on NOC, on 10/23/2021 only 1 AM/PM Guide scheduled, on 10/24/2021 only 1 AM/PM Guide scheduled and PM Lead Guide only worked 8PM-10PM, on 10/28/2021 only 1 AM Guide scheduled, on 10/29/2021 only 1 PM Guide scheduled, on 10/30/2021 only 1 AM Guide scheduled, on 11/01/2021 only 1 AM Guide scheduled, on 11/02/2021 only 1 AM Guide scheduled, on 11/03/2021 only 1 PM Guide scheduled, on 11/04/2021 only 1 AM Guide scheduled, on 11/05/2021 only 1 PM Guide scheduled, on 11/06/2021 no NOC Guide scheduled. The Topa Topa Building had a complaint with the same allegation and was substantiated in Complaint #29-AS-20210927103652.

LPA De Leon reviewed Facility staff notes on R1 it was reported on 09/28/2021 R1’s family suspected UTI and asked for a urine sample and push fluids, another note on 09/30/201 staff reported R1 frequency and odor in urine, 09/30 staff note later that day R1’s family worried about R1’s UTI, on 10/01/2021 a note by staff 6 (S6) indicating R1 has UTI and antibiotics are starting tonight.

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 8

Control Number 29-AS-20211115100401

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 4’s (W4) interview revealed on 09/28/21 R1’s family suspected a UTI, on 09/29/21 at 5:50 PM R1’s family asked S6 and was told the sample had been taken, then on 09/30/21 R1’s family inquired about the results of the specimen and was told it had not been taken and would be in the morning. W1 visited the facility on 10/01/21 around 11:30 AM and S6 stated the sample had not been taken so W1 helped R1 and provided a sample to the Guide on duty. Around 3:30 PM R1’s doctor notified W4 the pharmacy has an antibiotic to pick up, W4 picked up medication and went back to the facility around 5:00 PM, the Guide on duty said the medication would not be added to R1 medicine tray until this evening so W4 gave R1 1 dose of the medication and passed that information on to the Lead Guide Medication-Technician (MT) making sure the MT saw the medication and 1 tablet dispensed before leaving the facility. On 10/02/2021 W4 went to the facility at 2:30 PM the MT came to give Medication to R1 and explained that this was the morning dose as it had not been added to R1’s medicine tray. W4 said S6 lied to R’1 family about the specimen being take, S6 is overwhelmed with responsibilities and can not adequately manage the needs of the residents, due to understaffing. W4 feels the staff are not trained in memory care (MC) and with the lack of staff and lack of training, the staff do not seem to understand what to do when a MC resident is having an episode, behavior and the staff will say stuff to the resident that confuses the residents even more. W4 stated the facility has improved slowly since 2021 with staffing, the LVN has been replaced in the later part of 2022, the Administrator left but overall the facility still seems to be lacking in training for the jobs being performed.
LPA reviewed Medication Administration Records (MAR) for the months of September 2021- December 2021, specifically at the month of October 2021 and no Medications was listed for the order given to R1 on 10/01/2023. LPA De Leon was unable to determine from R1’s MAR when R1’s antibiotic medication was passed, not recorded, not scheduled, exception for not being given, or on hold.
Staff 1’s (S1’s) interview revealed S1 is aware of resident 1 (R1) falling and hitting head, R1 was sent out to the hospital, R1’s building Matilja is normally staffed with two caregivers working morning and evening shifts and 1 caregiver during the NOC shift, there are 5 residents in that building and S1 feels that 2 staff are sufficient to meet the resident’s needs, there is another resident in that building who gets agitated at the same time as R1 and they will both try to leave the building at the opposite ends, if staff need assistance staff can call the Med-Tech on duty to help out, and S1 does not assist residents with their medications.
Staff 2’s (S2’s) interview revealed S2 was not working when R1 fell, S2 is aware of R1 falling as S2 put it in the observation notes, S2 works in different buildings, S2 was working in the Matilija building 11/22/2021 and 2 caregivers were working in the building, S2 feels that 2 caregivers are enough for the 6 residents in the building, if a resident falls staff report it to the Med-Tech on duty, and S2 does not assist residents with medications.

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 8

Control Number 29-AS-20211115100401

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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Staff 3’s (S3) interview revealed that when R1 fell last R1 was sent out to the hospital, R1 was found on the floor during rounds by the NOC shift caregiver, R1 hit R1’s head and it was unwitnessed from S3;s understanding, S3 is not aware of R1 having any other falls, R1 will go door to door banging on other residents doors, R1 is repeatedly on overdrive due to R1’s diagnosis, there are 6 residents in the Matilija building and one of them is an Assisted Living resident not diagnosed with dementia, when a fall happens staff will notify the Med-Tech or the Nurse and they are the ones to notify the residents family and physician, S3 feels that R1 is a 1:1 as R1 needs to be followed throughout the day, S3 feels that they are meeting the residents needs with the current staffing, R1 will go days without sleeping, S3 does not feel the resident falling has anything to do with not having sufficient staffing, S3 feels that it has to do with the R1 not sleeping and becoming dizzy and unstable, R1 can walk very well and does not need support walking, and S3 does not assist residents with medications.
Staff 5’s (S5’s) interview revealed the kitchen person prepares the meals for the residents in the Topa Topa building and the Matilija building, S5 works in the Topa Topa 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, if staff do not do a shower on Monday, they will do it on Tuesday.
Staff 6’s (S6’s) interview revealed on days when they are short-staffed staff do not do full cooking of meals maybe frozen lasagna or frozen enchiladas, Management 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, 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.
Staff 7’s (S7’s) interview revealed in the Topa Topa Building 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.

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 8

Control Number 29-AS-20211115100401

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 1’s (R1’s) interview revealed that staff do not treat them well.

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’s) 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 this allegation is deemed Substantiated at this time.

On the allegation: Staff mishandled resident medications. LPA De Leon reviewed Facility staff notes on R1 it was reported on 09/28/2021 R1’s family suspected UTI and asked for a urine sample and push fluids, in another note on 09/30/201 staff reported R1 frequency and odor in urine, on 09/30/21 staff noted later that day R1’s family was worried about R1’s UTI, on 10/01/2021 at 4:49 PM a note was made by staff 6 (S6) indicating R1 has UTI and antibiotics were starting tonight.

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 8

Control Number 29-AS-20211115100401

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 4’s (W4) interview revealed on 09/28/21 R1’s family suspected a UTI, on 09/29/21 at 5:50 PM R1’s family asked S6 and was told the sample had been taken, then on 09/30/21 R1’s family inquired about the results of the specimen and was told it had not been taken and would be in the morning. W1 visited the facility on 10/01/21 around 11:30 AM and S6 stated the sample had not been taken so W1 helped R1 and provided a sample to the Guide on duty. Around 3:30 PM R1’s doctor notified W4 the pharmacy has an antibiotic to pick up, W4 picked up medication and went back to the facility around 5:00 PM, the Guide on duty said the medication would not be added to R1’s medicine tray until later that evening so W4 gave R1 1 dose of the medication and passed that information on to the Lead Guide Medication-Technician (MT) making sure the MT saw the medication and 1 tablet dispensed before leaving the facility. On 10/02/2021 W4 went to the facility at 2:30 PM the MT came to give Medication to R1 and explained that this was the morning dose as it had not been added to R1’s medicine tray. W4 said S6 lied to R’1 family about the specimen being take, is overwhelmed with responsibilities and cannot adequately manage the needs of the residents, due to understaffing. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Incident was not reported to the authorized representative. LPA reviewed facility staff notes which indicated R1 did have a fall on 09/09/2021 tripped by R1’s dog, a fall on 09/11/2021 where R1 landed on hip and R1 complained hip was sore and Responsible Party (RP) notified, R1 had a fall on 10/01/2021 around 6:30 AM by R1’s patio door, and at 9:40 AM R1 was found on the floor blocking bedroom door, on both falls R1 was lifted and put in bed, then again around 9:18 PM it was noted that R1 had an unwitnessed fall in R1’s bathroom and it states LVN and R1’s RP notified, then on 11/03/2021 Hospital Discharge note from a fall in morning RP notified, and then on 12/26/2021 unwitnessed fall with no pain or injury.
W4’s interview revealed W4 was never notified of any of the falls on 10/01/2021. W4 found out about the fall from another staff that on 10/01/21 R1 had suffered a fall which was not reported and there was a fresh open sore on the R1’s right shoulder.
The only fall in 2021 reported to Community Care Licensing (CCL) was dated 11/03/2021 and 911 was called. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, 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: 6 of 8

Control Number 29-AS-20211115100401

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...sufficient support staff shall be employed to ensure provision of personal assistance and care as required…Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds…This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide CCL with an up-to-date LIC 500 with each staff listed and job duty/title, provide CCL with a job description for each different position held and a list of the training the staff are provided to meet the job duty and description of the job held. Provide records to CCL.
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not comply with the regulation above the staff were not sufficient in number and competent to provide the services to meet the resident needs which posses 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 87465(c)(2)	1 2 3 4 5 6 7	(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need...(2)Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed Director over resident care and all medication technicians (MT) will be re-trained, re-tested, and provided with facility policy and procedures for passing medications, , Mandated Reporting and the training must meet the requirements of Regulations 87411, 87705 and 87707, provide proof of training to CCL with a current list of MT’s.
	8 9 10 11 12 13 14	Based on interview and records review the licensee did not comply with the above regulation R1’s medications once ordered by the physician were not given according to the physician’s direction which poses an immediate health, safety and personnel rights risk to residents in care.	8 9 10 11 12 13 14	Read/review CCL’s Medication Guide

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)

Page: 7 of 8

Control Number 29-AS-20211115100401

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 B 05/31/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	(a)…(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(D)Any incident which threatens the welfare, safety or health of any resident,...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to have all staff review facility policy and procedures on reporting, read and review regulation 87211, and mandated reporting requirements of Health and Safety Code 15630(b)(1) provide proof of review to CCL with an up to date LIC 500.
	8 9 10 11 12 13 14	Based on Interview and record review the facility did not report falls to the RP of R1 which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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)

Page: 8 of 8