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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 10/05/2021
Date Signed: 10/05/2021 05:35:53 PM

Document Has Been Signed on 10/05/2021 05:35 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:BROWN, MARY THERESAFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 72CENSUS: 38DATE:
10/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Michael O'NeillTIME COMPLETED:
04:00 PM
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210927103652 and 29-AS-20210608163749 investigation visits conducted on 10/5/21.

During facility tour on 10/5/21 with staff O'Neill starting at 11:19 am LPA observed vitamins A&D ointment and fragrance mist in an unlocked drawer in the Salon in the Topa Topa building accessible to residents. During facility tour starting at 11:35 am with staff O'Neill LPA observed dish soap, skin protectant cream, antibiotic ointment, alcohol antiseptic pad, sting relief pad and BZK antiseptic towlette in staff breakroom accessible to residents. During facility tour on 10/5/21 with staff O'Neill at 11:43 am LPA observed a knife in the kitchen of the Maricopa building accessible to residents. During an interview with resident #1 (R1) LPA observed Tums and benadryl in R1's room accessible to resident. LPA was advised by staff Jennifer Golob that the facility does not have documentation from R1's physician that R1 can administer and store their own medications.

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 $500.00.

Exit interview conducted, todays reports and civil penalties were reviewed and emailed to staff O'Neill.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2021
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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Document Has Been Signed on 10/05/2021 05:35 PM - It Cannot Be Edited


Created By: Joann Rosales On 10/05/2021 at 03:54 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: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff walked into kitchen to provide supervision of knife. Staff stated that he will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 10/6/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as a knife was observed accessible to residents which posed an immediate health risk to persons in care.
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Type A
10/06/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Staff placed items in an inaccessible location during facility visit. Staff stated that he will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 10/6/21.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as vitamins A&D ointment, fragrance mist were observed in the salon and tums and fragrance mist in R1's room where accessible to residents which posed an immediate health risk to persons in care.
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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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2021


LIC809 (FAS) - (06/04)
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