567609954-8-25-2021-29-AS-KHEN-C6EVSS-20210831164201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 08/02/2021
Date Signed: 08/25/2021 12:34:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210727094739

FACILITY NAME:	ARTESIAN OF OJAI, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR:	BROWN, MARY THERESA		FACILITY TYPE:	740
ADDRESS:	203 E EL ROBLAR DRIVE		TELEPHONE:	(805) 798-9305
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	72	CENSUS: 32	DATE:	08/02/2021
		UNANNOUNCED	TIME BEGAN:	11:17 AM
MET WITH:	Theresa Brown		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility did not seek timely medical care for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced subsequent complaint visit to the above facility to amend technical errors and clarifications on page 1 and 2 of complaint investigation report issued on 8/2/21.

During today’s unannounced complaint visit, Licensing Program Analyst (LPA) Angel Ascencio toured the facility, conducted interviews and obtained pertinent copies of documents. Entrance interview conducted with Administrator Mary Therese Brown.

During an interview with staff #1 (S1) at 11:23 AM, S1 stated that R1 had an unwitnessed fall on 7/26/2021. S1 mentioned that resident #1 (R1) did not hit their head but was experiencing pain in R1 groin area. S1 also added the R1 had gone to the hospital the week prior for another fall that caused an injury to R1 head on 7/17/2021 and that the R1 is now using walker to ambulate.
Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20210727094739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/02/2021

NARRATIVE

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LPA received a copy of R1 recent incident reports and a copy of their Observation Notes. LPA reviewed Observation notes and noted that R1 had additional falls on 7/22/21 and 7/27/21 that were not reported.

LPA noted the incident from 7/17/2021 was the only incident report the Regional Office (RO) obtained. LPA reviewed the Incident Report file for Artesian of Ojai in the RO servers, LPA noted no incident report reported for the falls on 7/22/21, 7/26/21 and 7/27/21.

At 12:45 PM, LPA reviewed R1’s file and care plan. LPA also received a copy of policies and procedures, specifically Fall Prevention and Management and Fall Response. Upon review of Physicians Report dated 10/28/2020, R1’s primary diagnosis is Alzheimer's Disease. R1 does not have wandering behaviors but needs stand-by assist with bathing and dressing and is ambulatory. LPA noted the R1’s care plan had not been updated from the time of admission, 10/28/2020. Upon reviewing care plan, LPA confirmed R1 does not have any physical limitations and can walk without assistance. R1 does not use a wheelchair, is ambulatory, and requires stand-by assistance for activities of daily living which is consistent with Physician’s Report that is dated 10/28/2021. At 2:52 PM, LPA interviewed R1’s family and noted that facility did not inform them of R1’s fall. The family added the only fall they are aware of was 7/17/2021 due to a medical bill that needed to be paid.

Between 3:10 PM and 3:45 PM, staff interviews were conducted. At 3:56 PM, LPA interviewed an additional family member of R1 who stated they did not receive a call for the falls that occurred on 7/22/2021,7/26/2021 and 7/27/2021. However, the family confirmed they received a call on 7/17/2021 fall after the incident happened. The interview also revealed if the family would have been made aware of the frequency of falls, they would have liked to have sought medical attention.

Based interviews and observation notes that were gathered during this visit, the department has sufficient evidence to determine that the allegation, facility did not seek timely medical care for resident, was not met. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of
Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210727094739

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 08/03/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	Admin stated they will report all falls to their LPA and will report changes to primary care physician and families. Admin will provide training to all staff and provide copy of material and attendees to LPA via email.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the facility did not seek timely medical care which poses an immediate health and safety risk to persons 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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