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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 07/12/2021
Date Signed: 07/12/2021 08:46:41 PM

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:BROWN, MARY THERESAFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:72CENSUS: 29DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mary Theresa BrownTIME COMPLETED:
03:30 PM
NARRATIVE
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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, random client rooms and restrooms were conducted. Outdoor area toured- passageways are free of obstruction.

PPE supplies were observed. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detectors were tested and were operable.

During facility tour with Administrator at 1:17 pm LPA observed hand soap, lotion and a bar of soap in resident #1 (R1) bedroom accessible to residents.

During facility tour with Administrator at 1:39 pm LPA observed dish soap, hand soap, multi surface cleaner, lotion, deodorant, hand sanitizer, razor, toothpaste, shampoo and conditioner in R2's bedroom accessible to residents.

During facility tour with Administrator starting at 1:46 pm LPA observed hand soap and a bar of soap in R3 and R4's bedrooms accessible to residents.

During facility tour with staff Orlando Nava at 2:07 pm LPA observed disinfectant spray under the outdoor barbeque grill accessible to residents.

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 $250.00
Exit interview conducted, todays reports and civil penalties were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (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.
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021

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, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/13/2021
Plan of Correction
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Administrator and staff placed toxic items in inaccessible locations during facility visit. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) from an outside vendor by 7/13/21.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (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
LIC809 (FAS) - (06/04)
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