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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 08:49:09 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mary Theresa BrownTIME COMPLETED:
07:21 PM
NARRATIVE
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On 7/8/21 LPA spoke with Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 7/3/21. Administrator stated that staff noticed the resident missing and made the assumption that R1 went for a walk. Administrator stated that R1 was found about a 5 minute walk away from the facility without any injury. Administrator stated that the door has a 3 second delayed egress and they thought that R1 may have followed a family member out of the building. R1's family member was notified of the incident. Administrator stated that they were going to be speaking with the company that installed the delayed egress to shorten the time.

LPA reviewed R1's records on 7/12/21 which revealed that R1 is not able to leave the facility unassisted.

During today’s visit LPA toured the facility with the Administrator. Administrator stated that staff were advised to watch the exit doors as visitors exit the building so that residents do not follow anyone out the door. Based on information obtained during the investigation staff failed to supervise R1 on 7/3/21 as R1 eloped from the facility.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):



Exit interview conducted, todays reports 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2021
Section Cited

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety 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 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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