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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850221
Report Date: 07/29/2022
Date Signed: 07/29/2022 06:52:05 PM

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
07/27/2022 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20220727150517
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: 13DATE:
07/29/2022
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Nicole ZandersTIME COMPLETED:
06:51 PM
ALLEGATION(S):
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Facility staff failed to administer resident medications as prescribed.
Facility staff are not keeping accurate records of residents cash resources.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a complaint investigation visit. LPA met with staff Nicole Zanders.

During today's visit LPA toured the facility with staff Zanders, interviewed staff, reviewed resident records and obtained copies of pertinent documents. Concerns were that facility staff failed to administer resident medicatons as prescribed as R1 was not given their medications on 7/2/22 to 7/6/22 and 7/11/12 and 7/12/22. A review of R1's medication records starting at at 1:32 pm with staff Zanders and S1 revealed that R1 was not given their morning medications from 7/1/22 to 7/6/22 and from 7/10 to 7/12/22. Staff #1 (S1) stated that R1 eloped from the facility. Staff Zanders stated that on 7/10/22 R2 signed out that they were leaving. Staff Zanders stated that they were not working on that day. At 3:20 pm LPA Rosales spoke with S2 who stated that R1 indicated on 7/10/12 that staff Zanders stated that it was ok for R1 to leave the facility. S2 stated that

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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 3
Control Number 29-AS-20220727150517
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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 07/29/2022
NARRATIVE
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they asked R1 to sign out when they leave the facility. S2 stated that they gave R1 their morning medications before they left. S2 stated that when they returned to work the next day R1 had not returned to the facility from the prior day. S2 stated that they do not know when R1 returned to the facility. S2 stated that they were not aware that R1 was unable to leave the facility unassisted. A review of random resident medications starting at 1:59 pm revealed that R2 has not been given their medications since 7/26/22 as staff Zanders stated that they spoke with R2 physician over the phone and they were told to hold all R2's medications for 48 hours. Staff Zanders stated that they do not have this information in writing. S1 stated that on 7/27/22 R2 refused all their medications as they were feeling sick. A review of R3's medications revealed that R3 is prescribed Triamcinolone lotion and the prescription label indicates 3 times a day however, the medication record reflects that it is being administered 2 times a day.

Concerns were that Facility staff are not keeping accurate records of residents cash resources as R1's cash resources were not being properly recorded. Interview with staff Zanders starting at 3:24 pm revealed that R1 moved into the facility on 5/31/22 and they did not have documentation of how much money R1 had when they moved into the facility. Staff Zanders stated that they kept receipts in a lock box with R1's cash. Staff Zanders stated that they did not keep a ledger of the accounting for R1's cash resources. Staff Zanders stated that R1 moved out of the facility on 7/23/22.

Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220727150517
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: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/30/2022
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care Services(a)(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Staff stated they will they will give resident medications as prescribed and will provide documentation of scheduled staff medication training to CCL 7/30/22. Staff will provide documentation of staff training to CCL by 8/8/22.
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Based on medication review, the licensee did not comply with the section cited above in 3 out of 7 resident medications which poses an immediate health risk to persons in care.
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Request Denied
Type B
08/05/2022
Section Cited
CCR
87217(g)(1)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables (g)(1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting...for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.
This requirement is not met as evidenced by:
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Staff stated that they will review and comply with the regulation and will submit documentation stating this to CCL by 8/3/22.
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as the facility did not keep a ledger of the accounting for R1's cash resources 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3