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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 03/08/2024
Date Signed: 03/08/2024 10:05:20 AM

Document Has Been Signed on 03/08/2024 10:05 AM - 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: 36DATE:
03/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jackie Sical-MC Care DirectorTIME COMPLETED:
10:10 AM
NARRATIVE
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 Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit. The purpose of the visit is to issue citations for deficiency observed during the investigation of an 11/18/2023 incident. LPA met with MedTech Alan Carrillo and explained the reason for the visit. Administrator Amber Winterstein was unable to be at the facility during today’s visit and authorized Care Director Jackie Sical to sign and receive the report.

During the investigation of an 11/18/2023 incident, the following deficiency was observed: Community Care Licensing (CCL) Investigator Christine Ferris noted that the facility failed to report suspected abuse of Resident #1 when staff reported concerns on multiple occasions.

On 03/27/2022, staff witnessed R1 with the suspected abuser (SA), who were both naked in the shower. The SA was a regular visitor and trusted family member of R1. On 10/18/2023, two (2) staff witnessed suspicious behavior between R1 and the SA while they were sitting on a bench. The staff reported their concerns for R1, yet the incident was not reported. The incident was documented with the facility, but not reported to CCL or Adult Protective Services (APS).

Citation issued, exit interview, appeal rights given.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 03/08/2024 10:05 AM - It Cannot Be Edited


Created By: Esther Cortez On 03/08/2024 at 09:05 AM
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: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/22/2024
Section Cited
CCR
87211(c)

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87211(c) Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the licensing agency, and the local law enforcement agency within twenty-four (24) hours.This requirement is not met as evidenced by:
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Licensee will conduct reporting requirement training for all staff. Training to be conducted by an outside vendor to include mandated reporting. Submit proof of training to CCL by 3/22/2024.
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Based on record review and interviews, the facility failed to report suspected abuse of R1, which posed an immediate health, safety, and personal rights risk to residents 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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