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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801114
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:46:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
02/07/2025 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20250207113310
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: 13DATE:
02/13/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Halina GarbaczTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff do not ensure residents’ toothbrushes are kept in a sanitary manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, LPA met with Administrator, Helina Garbacz and was explained the reason for the visit. Entrance interview conducted.

During today's inspection, between 10:50 a.m. and 2:50 p.m., the LPA, toured the facility, interviewed the Administrator, three (3) staff, five (5) residents, two (2) witnesses and observed residents at lunch.

Report will continue on LIC9099-C, 2nd page.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
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 4
Control Number 29-AS-20250207113310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
VISIT DATE: 02/13/2025
NARRATIVE
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Regarding the allegation, “Staff do not ensure residents’ toothbrushes are kept in a sanitary manner” it is the reporting party’s concern that the resident's toothbrushes are stored in a supplied closet along with cleaning supplies. At 11:21 a.m. the LPA observed seven (7) toothbrushes with no covers stored in an employee room stored with cleaning supplies. Toothbrushes were touching other toothbrushes bristles and did not have any labels on them to describe whom they belonged to. Upon observation, Administrator Halina revealed they belong to the residents, however was not able to state which brush belong to which resident. Based on the information obtained, the Department has sufficient evidence to support the allegation, therefore the allegation Staff do not ensure residents’ toothbrushes are kept in a sanitary manner, is Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)Exit interview conducted, a copy of this report and appeals rights issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250207113310
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: MANOR OF OJAI, THE
FACILITY NUMBER: 565801114
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents...
This requirement is not met as evidenced by:
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Licensee agreed to replace all 7 toothbrushes with new ones, and store them in a sanitary manner. Will submit proof to LPA no later than 2/13/2025.
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The Licensee did not comply with the section cited above as 7 out of 13 residents un covered toothbrushes were stored together, in a supply room whith cleaning supplies and bristles touching, which poses a potential safety risk to clients 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4