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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 07/30/2024
Date Signed: 07/30/2024 05:41:46 PM


Document Has Been Signed on 07/30/2024 05:41 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:AMBER L WINTERSTEINFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:72CENSUS: 38DATE:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Amber L WintersreinTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:40 a.m. Upon arrival, the LPA met with Administrator, Amber L Winterstein and the reason for the visit was explained. Entrance interview conducted.

INTERVIEWS: The LPA conducted three (3) resident interviews throughput the visit. No immediate concerns voiced at this time.

The LPA toured the physical plant areas inside and outside with the administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. 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:

KITCHEN: Each building has their own kitchen and dining area. The LPA inspected the kitchen/food service area at all four buildings. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Each kitchen/food service area has a locked knives and sharps drawer and a locked cabinet where the cleaning supplies are stored. Refrigerator and food pantry were checked for proper labels and expiration dates. At approximately 11:44 a.m., the LPA observed an untended pot of food on the stove which was left on in the Sespe kitchen/food service area. Upon observation, staff indicated they had just stepped out for a moment and turned off the stove. The LPA observed an adequate supply of emergency water.

COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature that ranged from 73*-75* degrees throughout the four buildings. Smoke detector(s) and carbon monoxide detectors tested were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 07/23/2024. The LPA observed required postings throughout the common spaces. The facility has a pool fully fenced with 2 locked gates for entry. Fireplaces were observed adequately screened. Report continued on LIC 809-C.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
VISIT DATE: 07/30/2024
NARRATIVE
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 BEDROOMS: The LPA observed ten random resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. All bedrooms inspected were observed to be unlocked. The LPA observed a sufficient supply of towels and linens. At 11:50 a.m. the LPA observed Room #216 in the Sespe Building to be unlocked. The LPA observed a kitchen knife on the counter accessible to other residents in care.

RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in two (2) random bathrooms in the Maricopa building (at 11:19 a.m. and 11:32 a.m.), and one (1) random bathroom in the Sespe, Maltija, and Topa Topa buildings (at 11:40 a.m., 12:03 p.m., and 12:15 p.m.) for a total of five (5) bathrooms. The temperature measured between 113.2 degrees Fahrenheit and 118.8 degrees Fahrenheit. At 11:39 a.m. the LPA observed a bottle of Mystical Cleaner stain remover deodorizer for carpet and upholstery in the bathroom of room 201 in the Sespe building. At 11:53 a.m. the LPA observed a bottle of glade air freshener , and a bottle of Rubbing alcohol in the bathroom of room 215 in the Sespe building. At 12:19 p.m. the LPA observed an unlocked staff bathroom in the Topa Topa building, the bathroom had a bottle of fabric and rug cleaner, a spray bottle of 300 waxie-green solution, and a bottle of Bonami scratch free powder cleanser.

RECORDS: At 2:05 p.m. a record review was initiated. Facility records are stored in a locked office. The LPA obtained Client Roster, Staff Roster and staff schedule. Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627C Consent for Emergency Medical Treatment forms, and current needs and services plan. The following was observed: three (3) of five (5) residents were missing LIC627C forms. Four (4) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, and first aid/CPR training. The following was observed: one (1) of five (5) staff (S1) was missing their health assessment with negative TB test result. Personnel training still needs to be reviewed. Due to time constraints the LPA will return to complete the annual at a later date.

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. Report was provided to the administrator.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/30/2024 05:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed a kitchen knife, disinfectants and cleaning solutions available to residents in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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 The Administrator agrees to do a full sweep of the facility for any item that could pose a danger to residents in care and secure all items, and submit a plan on how they will be ensure they are in compliance with regulation 87309 and submit to CCL by 07/31/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/30/2024 05:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 three of four resident files that were missing LIC627C consent for emergency medical treatment forms which poses a potential health and safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Administrator agrees to have obtain all missing LIC627C forms from the three residents and/or their authorized person, and make sure all residents have consent forms on file. Will submit proof to CCL by 08/09/2024.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/30/2024 05:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 567609954

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

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 one staff (S1) out of five staff as S1 does not have a health screening on their file with their tuberculosis (TB) information which poses a potential health and safety risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Admistrator agrees to have S1 get a healthscreening with TB results and submit proof of health screening and TB by 08/09/2024.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5