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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 04/21/2022
Date Signed: 04/21/2022 05:46:40 PM

Document Has Been Signed on 04/21/2022 05:46 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:PINK, TILLMAN JR.FACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 17DATE:
04/21/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nicole ZandersTIME COMPLETED:
05:44 PM
NARRATIVE
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Licensing Program Analysts (LPA) JoAnn Rosales arrived at the facility to conduct a Post Licensing visit. LPA met with staff Nicole Zanders - Executive Director who is authorized to review and sign reports.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Today's evaluation included but was not limited to building and grounds, resident rooms, bathrooms, common areas, personal accommodations, hot water temperature (read at 108, 77.9 and 118.4 degrees F) in resident bathrooms, kitchen and food supplies. There is an adequate amount of perishable and nonperishable foods. First Aid kit is complete. Grab bars were present in the bathrooms. LPA observed appropriate and sufficient lighting in each room. Hygiene items are being provided. LPA observed signal system which operates from each resident room. Staff Zanders was unable to test smoke alarms during facility visit however, LPA observed working smoke alarms during Pre-licensing visit of 9/30/21. Carbon monoxide detectors were tested and operable. LPA observed a 30 day supply of PPE. LPA reviewed a sampling of resident records.



During facility tour with staff Zanders on 4/21/22 at 10:15 am LPA observed video camera's located in the common areas inside the facility. LPA advised staff that they would need to include the use of video camera's in their plan of operation and admission agreements.

During facility tour with staff Zanders on 4/21/22 at 10:45 am LPA observed hot water temperature read at 77.9 degrees F in room #3's bathroom.


Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 04/21/2022
NARRATIVE
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During facility tour with staff Zanders on 4/21/22 at 12:21 pm LPA observed universal flooring adhesive, roof cement, all purpose interior/exterior primer in an unlocked room in backyard accessible to residents.

During facility tour with staff Zanders on 4/21/22 at 12:24 pm LPA observed gardening tools and lawn fertilizer in an unlocked shed accessible to residents.

During a review of resident records starting at 1:02 pm LPA observed that the facility failed to arrange a meeting with R1, R3, R4, R5, R6, R7, R8, R9 and R10, their representative, if any, when reappraisal was completed.

During a review of resident records at 1:58 pm LPA observed that R3 does not have a Pre-Admission Appraisal on file.

During a review of resident records at 2:09 pm LPA observed that R9 is bedridden and R9 is not in an approved bedridden room.

Due to time constraints LPA will need to return at a later date to continue the visit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties issued in the amount of $500.00.

Exit interview conducted, todays reports, civil penalty and appeals rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/21/2022 at 04:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/22/2022
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance (a)(2) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of...

This requirement is not met as evidenced by:
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Staff stated that they will provide documentation that they will move R9 to an approved bedridden room with approval of responsible person to CCL by 4/22/22.
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Based on LPA's observation and record review, the licensee did not comply with the section cited above in 1 out of 10 resident records which poses a potential health and safety risk to persons in care.
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Request Denied
Type B
05/02/2022
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance..
This requirement is not met as evidenced by:
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Staff stated that they will provide documentation of R3s Pre-Admission Appraisal to CCL by 5/2/22.
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Based on record review, the licensee did not comply with the section cited above in 1 out of 10 resident records which poses a potential health and safety risk to persons 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 04/21/2022
NARRATIVE
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During facility tour with staff Zanders on 4/21/22 at 10:55 am LPA observed a housekeeping cart in empty unlocked room #11 with bathroom creme cleanser, germicidal ultra bleach, air & fabric freshener and glass cleaner accessible to residents.

During facility tour with staff Zanders on 4/21/22 at 11:02 am LPA observed Refresh Tears, Lantus insulin pen and scissors in medication room accessible to residents as the keys were left in the door lock.

During facility tour with Staff Zanders on 4/21/22 at 11:08 am LPA observed disinfectant spray and skin protectant cream in room #9's bathroom accessible to residents.

During facility tour with staff Zanders on 4/21/22 at 11:26 am LPA observed an unlocked medication cart in the dining room accessible to resident with acetaminophen 500 mg tablets, systane eye drops, fluticasone nasal spray, olopatadine eye drops, simbrinza eye drops, fluorometholone eye drops, timolol eye drops, brimonidine eye drops, latanoprost eye drops, lumigan eye drops, spiriva capsules, triamcinolone lotion, refresh eye drops, ipratropium bomide, albuterol sulfate inhalation solution, polyethylene glycol, reguloid powder, gavilax powder, and benefiber powder.

During facility tour with staff Zanders on 4/21/22 at 11:42 am LPA observed antifungal cream with 1% clotrimazole and disinfectant spray in bathroom D1 accessible to residents.

During facility tour with staff Zanders on 4/21/22 at 11:55 am LPA observed milk of magnesia, stomach relief liquid, antacids, col-rite stool softener, antiobiotic ointment, allergy relief tablets, acetaminophen 500 mg caplets, hydrocortisone cream, iodine prep pads, robafen DM cough liquid, lotrimin antifungal spray, sunscreen, ricola throat drops, silver antimicrobial wound gel, RID home lice, bedbug & dust mite spray, RI lice killing shampoo, permethrin lotion 1% lice treatment in an unlocked upstairs room accessible to residents.

During facility tour with staff Zanders on 4/21/22 at 12:10 pm LPA observed 2 water system tanks in one of the outside passageways that leads to the exit of the side of the backyard.


Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/21/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/21/2022 at 04:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/22/2022
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff removed key from door lock and locked medication room during facility visit and will provide doumentation of locked shed to CCL by 4/22/22. Staff stated that they will provide documentation of staff training of regulation 87705(f)(1) to CCL by 5/2/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as scissors and gardening tools were observed accessible to residents which poses an immediate health and safety risk to persons in care.
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Request Denied
Type B
05/02/2022
Section Cited
CCR87463(c)

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87463 Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months…
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Staff stated that they will arrange a meeting with R1, R3, R4, R5, R6, R7, R8, R9 and R10, amd their representative, if any, and will provide documentation of signed reappraisals to CCL by 5/2/22.
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Based on record review, the licensee did not comply with the section cited above in 9 out of 10 resident records which poses a potential health and safety risk to persons 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


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Document Has Been Signed on 04/21/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/21/2022 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/22/2022
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed houskeeping cart in an inaccessible location, Staff placed toxic items in an inaccessible location, Staff locked upstairs room door and backyard room door during facility visit. Staff will provide documentation of staff training regarding regulation 87705(f)(2) to CCL by 5/2/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medications and toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.
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Request Denied
Type B
04/25/2022
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation. (e)(2)Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature…
This requirement is not met as evidenced by:
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Staff stated that they will provide documentation that they have turned up the water heater temperature and hot water temperature reads between 105 -120 degrees F in room #3's bathroom to CCL by 4/25/22.
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Based on LPA's observations the licensee did not comply with the section cited above as resident bathroom #3's water temperature tested at 77.9 degrees F which poses a potential health and personal rights risk to persons 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/21/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/21/2022 at 03:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/22/2022
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care Services (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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Staff removed keys from door lock and locked medication room door, staff locked medication cart during facility visit. Staff stated that they will provide documentation of staff medication training to CCL by 5/2/22.
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as residents medication was not kept in a safe locked place not accessible to residents which posed an immediate health risk to persons in care.
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Request Denied
Type B
05/02/2022
Section Cited
CCR87307(d)(6)

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87307 Personal Accommodations and Services (d)(6) The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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Staff stated that they will provide documentation of the 2 water system tanks moved from the outside passageway to CCL by 5/2/22.
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as 2 water system tanks are blocking the passageway leading to the outdoor gate which poses a potential safety and personal rights risk to person 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/21/2022 05:46 PM - It Cannot Be Edited


Created By: Joann Rosales On 04/21/2022 at 05:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/25/2022
Section Cited
HSC
1569.269(a)(2)

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1569.269 Enumerated rights; severability(a)(2) Residents of residential care facilities for the elderly shall have all of the following rights: To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone...
This requirement is not met as evidenced by:
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Staff stated that they will will not use video cameras without an an approved updated Admission Agreement and Program plan to include the use of video cameras in the common areas of the facility. Staff stated that they will submit a letter to CCL by 4/25/22 indicating this.
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as LPA observed video cameras in the common areas of the facility which poses a potential personal rights risk to persons 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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


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