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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 08/02/2021
Date Signed: 08/03/2021 10:58:44 AM

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: 32DATE:
08/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Mary Theresa BrownTIME COMPLETED:
05:20 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210727094739 investigation visit conducted on 8/2/21.

During interview with Administrator Therese Brown and S1 at 11:23 AM, it was stated that falls with obvious signs of injury get reported and get sent to the hospital for observation while falls with no injuries don't get reported mentioned by their last LPA. LPA observed 1 incident reported on 7/17/2021, while observation of care notes stated that R1 had a 3 total falls starting on 7/22, 7/26 and 7/27. The Woodland Hills office did not received any additional incident reports regarding 7/22, 7/26 and 7/27 falls. During F1 interview at 2:52 PM, F1 mentioned that they were not made aware of any of the falls. F1 added the only reason they knew about the falls was due to a medical copay bill from the hospital. F1 then proceeded to call the facility to confirm the fall. During, F2 interview at 3:56 PM, F2 stated they did not receive any calls or were made aware of falls R1 had besides the 7/17/2021 incident.

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 reviewed and email to administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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: 08/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited

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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified.
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Based on record review and observations, the licensee did not comply with the section cited above as the facility did not report in a timely matter to the licensing agency which poses a potential health and safety risk to persons in care.
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Type B
08/20/2021
Section Cited

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87463 Reappraisal (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months...
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Based on interview and record review, the licensee did not comply with the section cited above as the facility did not report the changes in conditions to the appropriate representatives which poses a potential health and safety risk in 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: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2021
LIC809 (FAS) - (06/04)
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