567609954-1-27-2022-29-AS-JROS-CB42QG-20220127163556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609954
Report Date: 01/27/2022
Date Signed: 01/27/2022 04:36:28 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, THE		FACILITY NUMBER:	567609954
ADMINISTRATOR:	MICHAEL O'NEILL		FACILITY TYPE:	740
ADDRESS:	203 E EL ROBLAR DRIVE		TELEPHONE:	(805) 798-9305
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	72	CENSUS: 38	DATE:	01/27/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Michael O'Neill		TIME COMPLETED:	04:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management visit to the facility. The case management visit is being conducted to discuss the incident of 1/16/22 for resident #1 (R1).

On 1/16/22 at approximately 2 am staff #1 (S1) observed bruising on R1's face on their forehead and across the bridge of their nose. S1 stated that R1 did not fall and they did not notify staff Supervisor Jennie Golob LVN about the bruising until 6 am by text message as they had assumed that they had already been notified about the bruising. R1's Hospice nurse and family member where notified about the bruising.

During facility visit LPA toured the facility with the Administrator, interviewed R1 and random staff and obtained copies of pertinent documents. A review of R1's records starting at 2:50 pm revealed that on 1/16/22 at 6:09 am LVN Golob received picture of bruising on R1's forehead, bridge of nose and pointer finger on right hand. On 1/6/22 at 1:49 am staff #1 (S1) reports that they did not know what happened to R1 when they checked on R1 at 2 am the bruising was there already. S1 stated that they thought it was it already reported. On 1/16/22 S2 was called to assess R1 who was walking in their room and had a large swollen area above their right eye and across the bridge of their nose that had some discoloration. No falls were witnessed and staff did not know how it happened. 1/16/22 at 6:45 am S2 called hospice for a visit for R1. 1/16/22 at approx 10:15 am staff were notified that hospice would not be going to see R1 today but to notify of any changes. 1/16/22 11:00 am R1 complained of pain while sitting up and pain in chest a PRN was given. 1/16/22 11:45 am R1 complained of pain in their belly and not their chest. Hospice was notified and LVN Golob. Hospice recommended to give R1 medication and stated that they would be out to see R1

Continued on 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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
	VISIT DATE: 01/27/2022

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tomorrow. Based on the information obtained during the course of the investigation LPA has determined that the facility did not call 911 on 1/16/22 when bruising was observed on R1 face.

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

Civil penalties issued in the amount of $250.00.

Exit interview was conducted, today's reports, civil penalties and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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: 01/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2022 Section Cited	1 2 3 4 5 6 7	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). This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as staff did not call 911 on 1/16/22 when bruising was observed on R1’s face which poses an immediate health 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

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: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

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