567609954-7-13-2021-29-AS-KBUY-CSCLUS-20230531090423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 07/12/2021
Date Signed: 07/13/2021 10:42:48 AM

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 Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210707125403

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: 29	DATE:	07/12/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Mary Theresa Brown		TIME COMPLETED:	07:21 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not administer resident medications according to physician orders
Staff did not keep accurate medication records for resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

During today's visit Licensing Program Analyst (LPA) JoAnn Rosales toured the facility with the Administrator, reviewed random resident medications and records and obtained copies of pertinent documents.

Concerns were that facility staff were not administering resident medications according to physician's orders. During a review of 4 of 4 resident medications with staff Jennifer Golob starting at 3:30 pm LPA observed that resident #1 (R1)'s Alprazolam 0.25 mg tablet was not given on 7/4, 7/5/ 7/10 and 7/11 at 2:30 pm and on 7/12/21 at 8:00 am as prescribed, Vitamin B12 was not given on 7/2, 7/5, 7/7, 7/9 and 7/12/21 as prescribed, Vitamin D3 was not given from 7/1 to 7/12/21 as prescribed, Atorvastatin 20 mg tablet, Calcium 600 MG tablet, Mapap arthritis pain oral tablet and Metformin HCI oral tablet not given on 7/12/21 as prescribed. R2's Pantoprazole 40 mg tablet was not given on 7/12/21 as prescribed. R3's Aspirin 81 mg, Cetirizine HCI 10 mg tablet, Vitamin D3 tablet, Terazosin HCI 10 mg capsule, Refresh eye drops, Fluticasone nasal spray, Methenamine oral tablet, Finasteride oral tablet colace capsule and divalproex 125 mg capsules were not
Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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 4

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: 07/12/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

given on 7/6 and 7/12 as prescribed. LPA observed that R4 was not given Furosemide 20 mg tablets on 7/2/21 as prescribed. LPA observed that the facility did not have a refill for R3's colace capsules. Concerns were that staff were not keeping accurate medication records for resident. During a review of 1 of 4 resident medications with staff Jennifer Golob LPA observed that R1's Alprazolam 0.25 mg tablet was prescribed to be given every morning and at 2:30 pm also up to every 6 hours as needed for agitation. The MAR indicates instructions as 1 tab PO daily at 8:00 am and 3:00 pm. Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 07/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/13/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care Services(a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that they will provide documentation of scheduled staff medication training to CCL by 7/13/21.
	8 9 10 11 12 13 14	Based on medication review, the licensee did not comply with the section cited above in 4 out of 4 resident medications which poses an immediate health risk to persons 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4