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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 06/09/2022
Date Signed: 06/09/2022 05:13:34 PM

Document Has Been Signed on 06/09/2022 05:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, 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: 45DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michael O'NeillTIME COMPLETED:
05:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Michael O'Neill and staff Jennie Golob.

During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted hot water temperature (read at 117.6, 101.9, 115.4 and 87.7 degrees F.) in resident bathrooms. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed a sufficient supply of perishable and nonperishable food. LPA observed working signal system in each building. LPA observed appropriate lighting in the facility. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detectors were tested and were operable. Disinfectants and cleaning supplies were in locked cabinets under the kitchen sink in each building and in the locked pool room. Medications were centrally stored and are kept in a locked medication rooms. LPA observed a sufficient supply of PPE. Outdoor area toured- passageways are free of obstruction.

During facility tour on 6/9/22 at 1:17 pm with Administrator and staff Golob LPA observed a razor in Resident #1 (R1)'s bathroom (Maricopa) accessible to residents.

During facility tour on 6/9/22 starting at 1:35 pm with Administrator and staff Golob LPA observed scissors, dish soap, biotene dry mouth lozenges, systane eye drops, refresh tears eye drops, and arnicare pain relief gel in R2's bedroom (Maricopa) accessible to residents.

Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/09/2022
NARRATIVE
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During facility tour on 6/9/22 at 1:58 pm with Administrator and staff Golob LPA observed hot water temperature at 101.9 degrees F. in resident bathroom (Sespe building).

During facility tour on 6/9/22 at 2:10 pm with Administrator and staff Golob LPA observed shampoo in R3's shower (Matilija) accessible to residents.

During facility tour on 6/9/22 at 2:31 pm with Administrator and staff Golob LPA observed hot water temperature at 87.7 degrees F. in resident bathroom (Topa Topa building).

During facility tour on 6/9/22 at 2:33 pm with Administrator and staff Golob LPA observed staff #1 (S1) working and not associated to the facility. Administrator stated that S1 works for an agency. S1 stated that they work for 1 Heart Agency. Staff Golob stated that today is the first day S1 has worked at the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties assessed in the amount of $600.00.

Exit interview conducted, todays reports and civil penalties were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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Document Has Been Signed on 06/09/2022 05:13 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/09/2022 at 04:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was associated to the facility prior to allowing S1 to work which poses an immediate safety risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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S1 requires to obtain criminal transfer. Staff associated S1 through Guardian System during the facility visit. Administrator stated that they will not employ staff unless they are associated with the facility.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above as a razor and scissors were observed accessible to residents which poses an immediate safety risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Staff placed razor and scissors in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(1) and will staff conduct resident room checks. Administrator stated that they will provide R2 with a key to their room to maintain a locked door for safety. Administrator stated that they will provide documentation of staff training to CCL by 6/20/22.
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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/09/2022 05:13 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/09/2022 at 04:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as Over-the-counter medication and toxic substances were accessible to residents which poses an immediate health risk to persons in care.
POC Due Date: 06/10/2022
Plan of Correction
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Staff placed Over-the-counter medication and toxic substances in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(2) and will staff conduct resident room checks. Administrator stated that they will provide R2 with a key to their room to maintain a locked door for safety. Administrator stated that they will provide documentation of staff training to CCL by 6/20/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/09/2022 05:13 PM - It Cannot Be Edited


Created By: Joann Rosales On 06/09/2022 at 04:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in 2 out of the 4 buildings which poses a potential health and personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Staff turned up water heater temperature during facility visit. Administrator stated that they will maintain hot water temperature between 105 and 120 degrees F.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


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