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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 03/23/2023
Date Signed: 03/23/2023 06:34:11 PM

Document Has Been Signed on 03/23/2023 06:34 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:GARY Y LEEFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 15DATE:
03/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Gary LeeTIME COMPLETED:
06:30 PM
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Licensing Program Analysts (LPAs) Esther Cortez and Zabel Chochian conducted an unannounced Case Management – Deficiencies visit on 03/23/2023, in conjunction with complaint control #29-AS-20230315122126.

During the course of the investigation of the above noted complaint, it was discovered the administrator did not do the following:

-obtain a hospice care plan for Resident #1 (R1) and Resident #2 or retain any hospice records


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

Exit interview conducted, today's reports and appeal rights were reviewed and issued to administrator
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2023 06:34 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/23/2023 at 06:05 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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87633(h)

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87633 Hospice Care of Terminally Ill Residents(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plano hspice agency, and the resident; or the resident's
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Administrator will submit a written plan for obtaining and retaining hospice care plans and hospice records. This will be provided to CCL by 03/30/2023. Also provide copy of the hospice care plan for R1 and R2 by 03/30/2023.
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Health Care Surrogate Decision Maker if the resident is incapacitated. This requirement was not met as evidenced by: Licensee had no records regarding R1's and R2's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital risk to resident 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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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