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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:46:45 PM

Document Has Been Signed on 08/08/2024 04:46 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR/
DIRECTOR:		AMBER L WINTERSTEINFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 72CENSUS: 38DATE:
08/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Amber L WintersreinTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/30/2024. The LPA met with Administrator, Amber Winterstein and informed them of the reason for the visit. Entrance interview.

Today the LPA conducted two (2) staff interviews, a medication audit and finished the record review initiated on 7/30/2024.

Record Review: The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/18/2024). The LPA also reviewed Personnel Training. The following was observed: S1 is missing six (6) required annual training hours in dementia, and two hours and thirty minutes (2.5) required annual training hours in Postural supports, restricted health conditions, and hospice. S2 is missing 3.25 hours in dementia, and 2.50 hours in Postural supports, and restricted health conditions. S3 is missing 2 hours in Postural supports, restricted health conditions. S4 is missing 2 hours in policies and procedures regarding medications, 2 hours in postural supports and restricted health conditions.

Medications: At 1:25 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in a Medication room, which is locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed two (2) PRN medications not documented in the Facility Centrally Stored Medication and Destruction Record (CSMDR). Upon observation, MedTech recorded the medications on the CSMDR. The LPA also observed three (3) PRN medications with a start date, however all 3 medications had not been started, and one (1) PRN medication had the wrong start date noted on the CSMDR.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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Document Has Been Signed on 08/08/2024 04:46 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/08/2024 at 04:14 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four (4) out of fve (5) staff did not have their full 20 hours of required training which poses a potential health and safety risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Administrator will ensure that all staff who require 20 hours annual training will have it completed by 08/22/2024. Administrator will email training logs to CCL by due date.
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 record review, the licensee did not comply with the section cited above as two (2) medications were not centrally stored, 3 medications were recorded they had been started when they were not, and 1 medication had the wrong start date recorded which posed a potential health and safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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Upon observation, MedTech corrected all errors observed. Administrator agrees to have all MedTechs trained on regulation 87465(h) and submit to CCL by 08/22/2024
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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