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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801114
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:30:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220811121523
FACILITY NAME:MANOR OF OJAI, THEFACILITY NUMBER:
565801114
ADMINISTRATOR:HALINA GARBACZFACILITY TYPE:
740
ADDRESS:108 W. EUCALYPTUS ST.TELEPHONE:
(805) 646-1489
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:44CENSUS: 14DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Halina GarbaczTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Neglect/Lack of Supervision – Resident #1 (R1) wounds were infested with ants.
Neglect/Lack of Supervision – Staff members failed to reposition Resident #1 (R1)
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegations. The initial complaint visit was conducted on 08/12/2022 by LPA Camara. During today’s visit, LPA met with administrator Halina Garbacz and director of operations Bryant Barron and explained the reason for the visit.

On 08/11/2022, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that R1’s wounds were infested with ants and staff members failed to reposition R1. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Peter Zertuche.

(continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 5
Control Number 29-AS-20220811121523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
VISIT DATE: 11/29/2022
NARRATIVE
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On 08/12/2022, from 9:25am to 11:30am, LPA Camara conducted the initial 10-day complaint visit. The LPA met with administrator Halina Garbacz and assistant administrator Bryant Barron and explained the reason for the visit. During the visit, LPA conducted a brief facility tour at 9:30am and reviewed and obtained pertinent documents starting at approximately 9:55am. The administrator was notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) for further investigation.

Investigator Zertuche conducted an interview on 08/17/2022, at approximately 4:00pm, with a Hospice staff; on 09/01/2022, at approximately 12:00pm, with a Hospice nurse; on 09/02/2022, from approximately 10:00am to 1:30pm, with facility administrator, a facility staff, facility residents, and R1’s resident representative; an attempt to conduct an interview with Staff #1 (S1) was made at approximately 1:00pm, however, S1 did not return the phone call. On 09/20/2022, at approximately 12:30pm, Investigator Zertuche contacted the Ventura County Sheriff’s Department and was informed that there was no report on file for this case; at approximately 1:00pm, the investigator contacted the Long Term Care Ombudsman (LTCO) and was informed that they received a report of the incident. Additionally, Investigator Zertuche reviewed copies of R1’s Hospice records.

A review of the hospice records revealed R1 was on hospice care and diagnosed with end-stage dementia and Ischemic Cardiovascular disease. R1 was bedridden and required assistance with most activities of daily living. On 08/08/2022, at approximately 8:00am, the hospice aide found R1 covered in ants and R1’s adult diaper completely saturated along with a new wound on the right upper shoulder. The hospice aide contacted the hospice agency and informed the nurse of the findings. The hospice nurse visited the facility later that day at approximately 4:00pm. By then, R1 was clean, and the bedding and room were also clean. The nurse observed an open wound to the top of the shoulder which measured at stage III. Since R1 was declining and on hospice, R1 was bed bound, weak, did not eat well and skin was thin which required regular repositioning. However, it appeared as if R1 was not being repositioned or checked on based on R1’s diaper being soiled, a new injury forming, and ants found all over R1’s body. There were no logs documenting R1’s care. No photos were taken and R1 was not sent to the doctor since R1 was receiving hospice care. There were no issues documented prior to this date and subsequent visits showed R1 and R1’s room were clean with no concerns.

(continued on 9099-C)
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220811121523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
VISIT DATE: 11/29/2022
NARRATIVE
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The administrator stated she was the only staff member present during the overnight hours. She stated she is the only person who works overnight and does not sleep. She stated she sleeps in the afternoons when other staff are present. On 08/08/2022, one staff member arrived at 7:30am, which was shortly before the hospice aide arrived. The administrator stated she checks and repositions the residents every two hours. However, she reported changing R1’s diaper at 4:30am but not again until the hospice aide arrived around 8:00am. The administrator admitted to not knowing about the new wound on R1’s shoulder until hospice informed her. Staff #2 (S2) stated they were not working on 08/08/2022. S2 stated they change R1’s diaper when it is wet, usually every few hours, but does not reposition R1 since it is difficult to get R1 out of the bed. S2 stated prior to leaving their shift on Sunday evening, 08/07/2022, they did not notice anything unusual on R1, including ants or any new injuries.

On the allegation - Neglect/Lack of Supervision – Resident #1 (R1) wounds were infested with ants – The administrator stated she was the only person working the overnight shift and reported she last checked on R1 at 4:30am the day of the incident on 08/08/2022. The administrator stated she repositioned R1 every two hours, but the next check on R1 was by the hospice aide at approximately 8:00am. Additionally, the administrator had no knowledge of the new wound on R1’s shoulder, which was an open wound at stage III, according to the hospice nurse. Furthermore, when the hospice aide arrived the morning of the incident, R1 was covered in ants throughout R1’s body and R1’s diaper was soiled. The hospice nurse, a credible witness, determined there was neglect in this case as it did not appear as if R1 was checked on for quite some time for R1’s body to be covered with ants and diaper soiled. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Neglect/Lack of Supervision – Resident #1 (R1) wounds were infested with ants, is Substantiated at this time.


(continued on 9099-C)
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220811121523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
VISIT DATE: 11/29/2022
NARRATIVE
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On the allegation - Neglect/Lack of Supervision – Staff members failed to reposition Resident #1 (R1) - The administrator stated she was the only person working the overnight shift and reported she last checked on R1 at 4:30am the day of the incident 08/08/2022. The administrator stated she repositioned R1 every two hours, but the next check on R1 was by the hospice aide at approximately 8:00am. Additionally, the administrator had no knowledge of the new wound on R1’s shoulder, which was an open wound at stage III, according to the hospice nurse. Furthermore, when the hospice aide arrived the morning of the incident, R1 was covered in ants throughout R1’s body and R1’s diaper was soiled. The hospice nurse, a credible witness, determined there was neglect in this case as it did not appear as if R1 was being repositioned, as was needed. S2 also admitted they do not reposition R1. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Neglect/Lack of Supervision – Staff members failed to reposition Resident #1 (R1), is Substantiated at this time.

A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220811121523
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services.
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).
This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure proper care and supervision is being provided to the residents. Submit to CCL by 12/02/2022.
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Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided proper care and supervision which resulted in R1 sustaining a stage III wound to shoulder infested with ants, which posed an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5