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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800551
Report Date: 06/09/2022
Date Signed: 06/10/2022 08:44:44 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2022 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20220601105540
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: 79DATE:
06/09/2022
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Matthew DiGrigoliTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Facility staff did not assist resident with medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 11:02AM and met with Executive Director Matteo DiGrigoli and Assisted Living Director Deedee Quolas. Entrance interview conducted.

During today's visit, LPA toured the facility with Mr. DiGrigoli at 11:15AM, conducted interviews with staff at 11:05AM, 1:07PM, and 1:48PM, LPA reviewed pertinent records at 11:32AM, and LPA gathered copies of pertinent documents. The following was then determined:

Resident #1 (R1) was admitted to hospice on 05/18/2022. Following hospice admittance, R1 had regular hospice visits by the nurse and others on the hospice care team. R1 sustained 2 falls on or around 05/26 and 05/27/2022. After the falls, R1's physician changed R1's medication orders. Facility staff documented medications administered by the facility, as well as when R1's family member administered medications.
REPORT CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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 2
Control Number 29-AS-20220601105540
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GABLES OF OJAI, THE
FACILITY NUMBER: 565800551
VISIT DATE: 06/09/2022
NARRATIVE
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Between 05/27/2022 and 05/31/2022, R1's family members were at R1's bedside both during the day and at night. R1's family member requested and administered PRN medications to R1. Review of hospice admit paperwork indicates R1's family member was "explained medications, dosage, routes, side effects, and schedule of administration" for R1's medications. Hospice paperwork further states "provided and discussed written policy and procedures on the management and disposal of controlled medications," indicating R1's family member, who is also designated as R1's Power of Attorney (POA) has been trained on proper administration of R1's medications. Staff interviews revealed R1's family member requested medications for R1 often, but they were prescribed every hour as needed for pain or shortness of breath and documentation review revealed the medication was not given to R1's family member to administer more often than prescribed. Therefore, based on interview and record review, the allegation that "Facility staff did not assist resident with medication as prescribed" is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview was conducted with Executive Director Matteo DiGrigoli. A copy of the report was provided via email.
SUPERVISORS NAME:
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2