567609954-5-3-2023-29-AS-KBUY-CSC4Q9-20230530191757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:40:31 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
06/04/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20210604105830

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: 47	DATE:	05/03/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mike O'Neil, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care
Insufficient staff to meet residents' needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint allegations. LPA met with the current Administrator Mike O’Neil and explained the purpose of the visit.

LPA Dulek conducted the initial 10-day complaint visit on 06/07/2021 at 11:10 AM – 1:10 PM, LPA toured facility, conducted interview, reviewed resident records, and requested copies of pertinent documents. LPA Ascencio conducted a subsequent complaint visit on 08/25/2021 at 12:30 PM – 4:00 PM, toured inside and outside of the facility, toured 13 resident rooms and unsubstantiated the allegation “Facility not maintained clean and sanitary at all times”. LPA Ascencio conducted staff interviews on 08/25/2021 at 3:21 PM, 3:32 PM, 3:36 PM, on 05/05/2022 at 2:50 PM. LPA De Leon reviewed all documents collected and requested additional documents on 04/24/2023 and reviewed those documents on 04/26/2023.

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: 05/03/2023

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 5

Control Number 29-AS-20210604105830

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: Resident sustained pressure injuries while in care. LPA Ascencio interviewed staff which revealed 2 out of 4 staff interviewed stated that R1 had a wound/open sore around May or June of 2021. Home Health and Hospice (HH) notes stated R1 was receiving wound care at the facility from 05/24/2021- 07/07/2021 and on 09/03/2021 R1 was noted with some redness on buttocks. HH notes from 09/10/2021 state left buttock stage 2 pressure injury and sacral stage 2 pressure injury. Facility staff notes indicate on 04/15/2021 at 9:38 PM rotating R1 often as R1’s sore on R1’s lower back looks irritated, on 04/21/2021 at 6:24 AM noted to other staff changed R1’s pad on R1’s coccyx during brief change, on 04/21/2021 at 10:13 PM noted R1 has irritation on R1’s groin area applied ointment, 05/10/2021 at 4:36 PM noted hospice nurse visit continue to treat wound on coccyx, on 05/13/2021 at 9:11 PM noted R1 has redness on buttocks notified med-tech ointment applied to the area, 05/16/2021 at 9:40 PM noted R1’s bottom is healing and looks less agitated but still needs care, prop R1 on side and keep clean from incontinence Medihoney seems to be working well on that area, on 05/22/2021 at 12:42 PM noted Hospice Nurse visit sacral wound continues to have redness but is improving since holding patches continue to monitor wound use barrier cream, on 05/24/2021 at 3:19 PM noted wound care surgeons made a visit today reported breakdown of skin at sacral area 1.0 X .05 left buttocks 1.5 X 1.5 instructions Medihoney to sacral wound and calmaseptine around wound, on 06/16/2021 at 3:49 PM noted nurse visited sacral wound improving redness decreasing continue to apply calmoseptine daily, on 06/17/2021 2:31 pm noted buttocks area very red advised staff, on 06/21/2021 at 9:50 PM noted Coccyx very red and opening back up applied barrier cream and Medahoney, on 06/22/2021 at 10:01pm noted R1 dinner in bed due to redness on buttocks, on 06/23/2021 at 1:46 PM noted R1 in bed all day due to R1’s bottom rotating R1 every 2 hours, on 06/23/2021 at 9:51 PM noted R1 repositioned every 2 hours applied cream to buttocks area, on 06/24/2021 at 2:18 PM noted rotated every 2 hours wound on buttocks looks better than yesterday, on 06/2/2021 at 10:02 PM noted repositioned every 2 hours applied cream to buttocks, on 06/25/2021 at 1:02 PM noted R1’s has skin tear on bottom size of a 50 cent piece and second tear about size of a nickel cleaned both with antiseptic gel and put calmoseptine ointment around it waiting on Medihoney from pharmacy notified staff of skin tear,

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (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 5

Control Number 29-AS-20210604105830

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 07/01/2021 at 1:45 PM noted R1’s wound is looking better, on 07/04/2021 9:16 PM noted while cleaning R1 noticed R1 has odor coming from sore on R1’s coccyx, on 07/07/2021 at 4:18 PM noted continue treatment for sacral wound, on 07/10/2021 9:49 PM noted left R1’s brief undone so R1’s coccyx could get fresh air there was a little open spot on right side, on 07/25/2021 at 2:06 PM noted cleaned spot on R1’s bottom and applied Medihoney there seems to be a spot that opened up right in the crease of R1’s behind fairly small. Staff 1/4 interviewed stated R2 had a bed sore in May 2021. R2 had a hospice note from 04/2/2021 R1 has an unusual opening on coccyx 1cm does not present as a wound and on 05/14/2021 at 12:16 PM staff notes stated Hospice Nurse visit Nurse will be discontinuing wound tx on coccyx the spot staff called a wound was a tail removal over 40 years ago. Staff interviews stated both R1 and R2 were on hospice services. Incident reports to Community Care Licensing (CCL) were reviewed and nothing was submitted for R1 and R2 had 1 incident reported on 04/16/2021 that did not relate to wounds or pressure injuries. Based on the evidence R1 did have pressure injuries while living at the facility therefore the allegation is deemed Substantiated at this time.

On the allegation: Insufficient staff to meet residents' needs. LPA De Leon reviewed documents on 04/26/2023 for staffing schedules from 05/30/2021 – 07/03/2021 the Topa Topa building where R1, R2 reside is normally scheduled with 1 AM Lead staff and 3 AM Guides, 1 PM Lead staff and 3 PM guides, 1 NOC Lead that covers 3 separate buildings including the Topa Topa and 1 NOC guide, often these schedules go down to 2 guides when 3 are scheduled or the full shifts are only covered for a few hours on some days. LPA De Leon record review revealed staff notes stating R2 was good, kept trying to stand up after dinner Responsible party (RP) was yelling at R2 to stop, RP asked for someone to walk R2 but staff let RP know staff weren’t able to at the moment and there was no note left to indicate staff were able to walk R2 later that evening. Staff notes reveal many residents in the Topa Topa building up during the NOC shift and the facility only staff’s 1 NOC guide in the building. Prior complaint interviews with staff revealed on 04/12/2021 on the NOC shift the 1 lead staff was scheduled to cover a building and each building was only staffed with 1 staff and the lead had to go to help the staff in the Topa Topa building leaving the other building unsupervised to help staff with a lift assist due to R2’s rolling out of bed and R2 requiring a 2 person assist to get R2 back in bed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (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 5

Control Number 29-AS-20210604105830

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 reviewed staff disciplinary records and staff 5 (S5) that works the NOC shift has been disciplined for falling asleep on shift and was eventually terminated from employment for the repeated disciplinary action, S5 worked the NOC shift so that would leave the building with out supervision. Resident 3’s (R3’s) interview stated that usually there is 1 caregiver on the NOC shift at night and they could not find them, that R3 pushes R3’s pendant quite often and it doesn't work, that R3 can go 4 or 5 days without a bath if R3’s does not ask and even if R3 does ask, night of 10/04/2021 R3 woke up at 5 am and hit R3’s pendant and waited and waited and nobody came, R3 looked out R3’s door and saw no one was around. Based on the evidence in the allegation is deemed Substantiated at the time. This deficiency was addressed and cited on Complaint #29-AS-20210422132534.

Exit interview conducted, deficiency 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: 05/03/2023

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 5

Control Number 29-AS-20210604105830

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 87468.1(a)(16)	1 2 3 4 5 6 7	(a)... (16)To receive or reject medical care or other services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to hold personal rights and mandated reporting training to all staff on all shifts and provide proof of training to CCL.
	8 9 10 11 12 13 14	Based on record review the licensee did not comply with the regulation above as R1 and R2 were not receiving the medical care and services needed 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: 05/03/2023

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)

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