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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800551
Report Date: 09/09/2021
Date Signed: 09/09/2021 03:48:39 PM

Document Has Been Signed on 09/09/2021 03:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GABLES OF OJAI, THEFACILITY NUMBER:
565800551
ADMINISTRATOR:DAVID SCARLETTFACILITY TYPE:
740
ADDRESS:701 N. MONTGOMERY ST.TELEPHONE:
(805) 646-1446
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 118CENSUS: 68DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Eric Terrill - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 8/26/21. LPA met with Eric Terrill - Administrator.

On 9/2/21 LPA spoke with staff Ashley Phelps regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 8/26/21. R1 was observed approximately 2 blocks from the facility and was redirected by staff back to the facility. R1 did not sustain any injuries. R1's primary care provider and family member were notified of the incident. Staff stated that based on R1's physicians report R1 is not able to leave the facility unassisted.

LPA reviewed R1's records on 9/7/21 which revealed that R1 is not able to leave the facility unassisted.

During today’s visit LPA toured the facility with staff Ashley Phelps. During facility tour starting at 10:41 am with staff Phelps LPA observed lysol disinfecting wipes, bleach, disinfectant cleaner, laundry detergent, fabric softener, oxi clean stain remover, lime-a-away cleaner, toilet bowl cleaner, and furniture polish in an unlocked housekeeping room accessible to residents.

Interview with Administrator at 3:28 pm revealed that R1 will be provided with 1:1 caregiving services until they are able to move R1 to the Gardens (Memory Care). Administrator stated that R1 is scheduled to move to the Gardens on 9/13/21. Based on information obtained during the investigation staff failed to supervise R1 on 8/26/21 as R1 eloped from the facility.

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



Exit interview conducted, todays reports were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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Document Has Been Signed on 09/09/2021 03:48 PM - It Cannot Be Edited


Created By: Joann Rosales On 09/09/2021 at 03:12 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: GABLES OF OJAI, THE
FACILITY NUMBER: 565800551

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited
CCR
87464(f)(1)(c)

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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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Administrator stated that R1 will be placed with a 1:1 caregiver starting immediately. Administrator stated that they will provide documentation of staff training regarding safety and elopement protocols to CCL by 9/20/21.
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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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Type A
09/10/2021
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff locked cabinet containing the lysol wipes, bleach, disinfectant cleaner, laundry detergent, fabric softener, oxi clean stain remover, lime-a-away cleaner, toilet bowl cleaner, and furniture polish. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) by 9/10/21.
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Based on LPA's observations, the licensee did not comply with the section cited above as cleaning supplies and disinfectants were accessible to residents 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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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