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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:21:08 PM

Document Has Been Signed on 02/02/2024 03:21 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: 37DATE:
02/02/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amber WintersteinTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Martha Arroyo and Valeria Conway conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/26/2023. LPAs met with Administrator, Amber Winterstein and informed them of the reason for the visit. Entrance interview.

During today’s visit, the LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations, conducted a file review, and conducted a medication audit.

There are four (4) resident buildings in total. Two (2) Assisted Living (Maricopa and Sespe) and two (2) Memory Care (Topa Topa and Matilija). The following was noted:

The LPAs inspected the kitchen/food service area in all four (4) buildings. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Between 11:58 a.m. and 12:30 p.m., LPAs observed the refrigerators and food pantry and checked for proper labels and expiration dates. At this times, canned goods, pasta, nuts, half and half, prune juice, and cream cheese were items found in poor condition as they were observed past their expiration date. Staff discarded all expired items at the time of the visit.

(Report Continued on LIC 809C...)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2024
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: 02/02/2024
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(Report Continued from LIC 809...)

Records: LPA’s reviewed Resident Records at 10:33 a.m. and Personnel Records at 11:08 a.m.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

Four (4) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.



Medications: Medications review began at approximately 12:35 p.m. The medications are centrally stored in each building. Medications are labeled and checked for expiration dates. PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file.

At 12:41 p.m., Resident #1’s (R1’s) six out of six medications reviewed indicated there were six (6) refills left; however, the centrally stored medications and destruction record (CSMDR) stated there were five (5) refills left for each medication. Staff stated they would contact pharmacy to verify information.

At 12:49 p.m., Resident #2's (R2’s) medication did not indicate the strength on the medication label. Additionally, at 12:56 p.m., R2’s centrally stored medication and destruction record was observed to not have the start date listed for their medication. Staff added start date on CSMDR at the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/02/2024 03:21 PM - It Cannot Be Edited


Created By: Martha Arroyo On 02/02/2024 at 02:57 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: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as, non-perishable items were found in poor condition as they were observed past their expiration date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Staff discarded all expired items at the time of the visit.

POC has been met.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review during medication audit, the licensee did not comply with the section cited above, as R2’s medication label did not list the strength for medication and the start date for medication was not logged into the CSMDR, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2024
Plan of Correction
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Staff added start date at the time of the visit and verified prescription information on labels.

POC has been met.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024


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