567609954-2-28-2025-29-AS-ECOZ-DEBVYT-20250228155141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 02/28/2025
Date Signed: 02/28/2025 03:52:50 PM

Document Has Been Signed on 02/28/2025 03:52 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, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR/ DIRECTOR:	DAVID SCARLETT		FACILITY TYPE:	740
ADDRESS:	203 E EL ROBLAR DRIVE		TELEPHONE:	(805) 798-9305
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY: 72		CENSUS: 42	DATE:	02/28/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:20 PM
MET WITH:	David Scarlett		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver an amended report with the finding for the above allegation. The report was initially issued on 03/08/2024 with an Unsubstantiated finding, however, upon further Department review, the finding is amended to Substantiated. LPA met with Executive Director David Scarlett and explained the reason for the visit. On 11/18/2023, the Department received a Report of Suspected Dependent Adult/Elder Abuse Report from the facility. The report advised on 11/18/2023, Resident #1’s (R1) family member/Suspected Abuser (SA) was observed with their penis in R1’s mouth. On 11/20/2023, the Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Christine Ferris to conduct the investigation in reference to the allegation. On 11/20/2023, from 1:50pm to 3:30pm, Licensing Program Analysts (LPAs) Elsie Campos and Emily Peraldi conducted an unannounced Case Management - Incident visit. At 1:55pm, LPAs Campos and Peraldi met with Administrator, Amber Winterstein and explained the reason for the visit. The reason for the visit was to follow up on a self-reported incident report received on 11/20/2023. The report pertained to a personal rights violation of Resident #1 (R1). At 1:58pm, the LPAs conducted an interview with the Administrator. At 2:06pm, the LPAs obtained copies of pertinent documents. At 2:55pm, the LPAs along with the Administrator conducted a physical plant tour. No immediate health and safety concerns were observed during the inspection. The LPAs determined further investigation was needed and informed the Administrator that the investigation was assigned to the Community Care Licensing (CCL) Investigations Branch (IB). Report will continue on LIC809-C, 2nd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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: 02/28/2025

NARRATIVE

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On 12/04/2023, from approximately 11:00am to 1:30pm, CCL IB Investigator Ferris conducted interviews with R1, Administrator, staff, and residents; on 12/19/2023, from approximately 11:30am to 1:00pm, with staff; on 01/19/2024 and 01/22/2024, attempted to contact the SA and left voice mails; and on 01/22/2024, at approximately 10:00am, with Detective Torres of the Ventura County Sheriff’s Department. In addition, Investigator Ferris requested Ventura County Sheriff’s Department Report #2023-147699 and facility file documents related to R1.

A review of R1’s Physician Report, dated 05/21/2023, lists R1’s primary diagnosis as end stage Cerebrovascular Disease with Dementia. The report also noted R1 was confused, disoriented with increased forgetfulness. R1’s health status was listed as poor. R1 required assistance with all activities of daily living and was receiving hospice care.

The investigation revealed that on 11/18/2023, at approximately 9:40am, facility Staff #1 (S1) stated they were delivering “punch cards” to the employee break room located in the southwest corner of the facility. The employee entrance opens into a long private pathway accessible to all residents and visitors. Located in the middle of the walkway was a bench. S1 turned the corner of the building to enter the break room and observed the SA standing over R1 with their penis in R1’s mouth. R1 was seated on the bench fully clothed facing the SA. S1 began yelling at the SA and walked towards them. As S1 got closer to them, the SA sat down on the bench beside R1 and S1 noticed the SA used their hands to cover their pants. S1 yelled at the SA for an explanation of what they witnessed, and the SA denied their actions. At approximately 9:42am, S1 used their radio to call for Staff #2 (S2) to come to the location and help get R1 back to their room. S1 told the SA to leave the location and when the SA stood, S1 noticed the SA’s pants were unzipped, and the SA’s belt was completely undone. S1 followed the SA until they left the facility. Once the SA was gone, S1 notified the supervisors and had R1 checked on. The Administrator then contacted the Ventura County Sheriff’s Office who continued the investigation. The detectives attempted to interview R1, but R1 was unable to give a relevant statement. The detectives took the SA into custody and arrested the SA for PC 287(a) Forcible Oral Copulation and PC 368(b)(1) Elder abuse.

Report will continue on LIC9099-C, 3rd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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: 02/28/2025

NARRATIVE

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The Department’s investigation further revealed that this was not the first unusual incident between SA and the R1. On 03/27/2022, staff observed SA showering with R1 while both were naked. While the facility did report the current incident to the police, the facility did not report the past incident of SA showering with R1. Staff also sent emails to the Administrator documenting strange interactions between SA and R1 – an indication that staff were suspicious of SA’s motives for regularly visiting R1. This was the second instance of SA sitting on the same bench with a shirt over their waist. Thus, the facility was aware of inappropriate behavior between SA and R1, and should have been more vigilant, or could have inquired with R1’s family members regarding the suspicious behavior. Therefore, there is sufficient evidence to substantiate lack of care by the facility staff. The allegation “Neglect/Lack of Care: Staff neglected and/or failed to provide an appropriate level of care resulting in Resident #1 (R1) being sexually abused by a family member” is deemed substantiated at this time.

A $500 immediate civil penalty is assessed today based on H&S 1569.49(c)(3).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2025 03:52 PM - It Cannot Be Edited

Created By: Esther Cortez On 02/28/2025 at 03:28 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: 02/28/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/28/2025 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit a plan how you will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 02/29/2025. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1)
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff were aware of inappropriate behavior between SA and R1, yet failed to prevent the continued interactions, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 02/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

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