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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800551
Report Date: 01/27/2022
Date Signed: 01/27/2022 01:48:48 PM

Document Has Been Signed on 01/27/2022 01:48 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:ERIC TERRILLFACILITY TYPE:
740
ADDRESS:701 N. MONTGOMERY ST.TELEPHONE:
(805) 646-1446
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 118CENSUS: 70DATE:
01/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Eric TerrillTIME COMPLETED:
01:48 PM
NARRATIVE
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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 1/23/22. LPA met with Eric Terrill - Administrator.

On 1/24/22 LPA spoke with the Administrator regarding an incident of Elopement for resident #1 (R1) on 1/23/22. R1 was missing for approximately 3 hours. Facility staff searched the immediate and surrounding areas and called the Sheriff's department. Administrator stated that they called in additional staff to help with the search. R1 was found at a home located next door to the facility sitting in an unlocked car. R1 was taken back to the facility by the Administrator. R1 did not sustain any injuries. R1's physician and family member were notified of the incident. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted.

During today’s visit LPA toured the facility with staff Naomi Hernandez and the Administrator. LPA conducted interviews with random staff and R1. A review of R1's records starting at 12:35 pm revealed that R1 is not able to leave the facility unassisted. Administrator stated that they conducted interviews with staff working at the time of the incident who indicated that they are not aware of how R1 left the facility. Administrator stated that the door alarms were functioning properly. Based on information obtained during the investigation staff failed to supervise R1 on 1/23/22 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
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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Document Has Been Signed on 01/27/2022 01:48 PM - It Cannot Be Edited


Created By: Joann Rosales On 01/27/2022 at 12:59 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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2022
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 was placed on frequent checks and they have started staff retraining regarding elopement protocols. Administrator stated that they will conduct a reappraisal for R1 and will provide a copy of reappraisal and staff training to CCL by 2/7/22.
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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 Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
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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