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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800551
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:31:48 PM

Document Has Been Signed on 05/03/2024 03:31 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GABLES OF OJAI, THEFACILITY NUMBER:
565800551
ADMINISTRATOR/
DIRECTOR:
MATTEO DIGRIGOLIFACILITY TYPE:
740
ADDRESS:701 N. MONTGOMERY ST.TELEPHONE:
(805) 646-1446
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 118CENSUS: 76DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Matteo DigrigoliTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Matteo Digrigoli and Assisted Living Director Dee Dee Heninger explained the reason for the visit.

The reason for today's inspection is to follow up on a self reported death report received on 05/01/2024. The report pertains to the death of Resident #1 (R1). Per the report received, R1 was involved in a collision with a vehicle while on their motorized scooter on 04-27-24. Emergency services and law enforcement were called to the location where the collision took place. R1 passed away on 04/28/2024 in the hospital.

During today's visit, the LPA conducted interviews with the administrator, two (2) staff, one (1) resident, conducted a file review and obtained copies of pertinent documents.

Interviews revealed that R1 was independent and that it was not unusual for R1 to often times leave the facility independently. Additionally, staff interviews revealed that they had not observed any change in condition since R1 was admitted to the facility. File review revealed that according to R1's last LIC 602 Physicians report R1 was independent and could leave the facility unassisted. According to R1's Care Plan, R1 was a assisted living resident admitted on 04/16/2022, R1 did not need assistance with any of their ADL's. Furthermore, R1's last appraisal dated 01/15/24 stated that R1 was active, independent, and did not require any personal help.

No Citations were issued during today's visit. Exit interview and copy of report printed for Administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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