Community Care Licensing

Document Has Been Signed on 12/28/2023 05:34 PM - It Cannot Be Edited

FACILITY NAME:	MANOR OF OJAI, THE		FACILITY NUMBER:	565801114
ADMINISTRATOR:	HALINA GARBACZ		FACILITY TYPE:	740
ADDRESS:	108 W. EUCALYPTUS ST.		TELEPHONE:	(805) 646-1489
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY: 44		CENSUS: 11	DATE:	12/28/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Halina Garbacz		TIME COMPLETED:	05:35 PM

SUPERVISORS NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023

Link to Parent Document Below:

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited aboveas for four staff (S1, S3, S4, S5) need a health screening and two staff (S1,S5) need TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Ensure all staff obtain health screeninng with TB test and submit proof to the LPA no later than 1/12/2024.

SUPERVISOR'S NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023

Link to Parent Document Below:

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as three staff (S3, S4, S5) did not have a criminal record statement LIC508 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	S3 is currently out of the country and not working at the facility, the Administrator agreed to obtain LIC508 for S4 and S5 and submit proof to the LPA no later than 1/12/2024.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023

Link to Parent Document Below:

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as five out of five staff were missing 40 hours of training in the required topics wich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	The Administrator has agreed to ensure all staff receive required training and submit proof to LPA by no later than 1/12/2024.

SUPERVISOR'S NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023

Link to Parent Document Below:

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one resident (R2) does not have TB results on file iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	The adminsitrator agreed to the following: 1. Ensure that R2 completes TB testing and provide proof of results to LPA no later than POC due date.

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as three out of five residents (R2, R4, R5) were missing appraisal/needs and services plans which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	The adminsitrator agreed to the following: 1. Ensure to complete the appraisal/needs and service plan for R2,R4 and R5 and submit proof to the LPA by 1/12/2024.

SUPERVISOR'S NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023

Link to Parent Document Below:

FACILITY NAME: MANOR OF OJAI, THE	FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

Type B

Section Cited

CCR

87507(c)

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one out five residents admission agreement was not signed by resident and/or residents responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	The adminsitrator agreed to the following: 1. Ensure that R2's admission agreement is signed by R2 and/or responsible party and submit proof to the LPA by 1/12/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kasandra Lopez LICENSING EVALUATOR NAME: Esther Cortez LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023