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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 03/30/2023
Date Signed: 03/30/2023 04:22:22 PM

Document Has Been Signed on 03/30/2023 04:22 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:GARY Y LEEFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 15DATE:
03/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Gary LeeTIME COMPLETED:
04:31 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Esther Cortez and Kelly Dulek conducted an unannounced Case Management – Deficiencies visit on 03/30/2023 beginning at 09:55AM.

During today's visit to the facility, LPAs, along with facility Executive Director Gary Lee, toured the facility at 11:03AM, and conducted a record review beginning at 12:30PM. The following was observed:

At 11:14AM, LPAs observed Glade Air Freshener, Windex wipes, and Oxi Clean Stain Remover in an unlocked cabinet in a resident's room. The door to the resident's room was observed to be open, accessible to all residents in care. LPAs also observed Ca-Rezz Incontinent wash in various resident rooms, on bedside tables, in unlocked common restrooms, and in resident restrooms. Record review revealed that three (3) of four (4) residents whose records were reviewed, have a diagnosis of dementia. Additionally, it was discovered that four (4) incidents occurred as follows: 03/02/2023 where S1 grabbed a resident by the nose, 03/02/2023 where S1 handled a resident roughly while changing them, 03/04/2023 where S1 sprayed incontinence wash in a resident's eyes, and 03/06/2023 where S1 argued and yelled at one resident, then yelled at a second resident and threw the facility telephone on the floor. None of these four (4) listed incidents were reported timely to CCLD nor to Regional Center.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). A civil penalty for repeat citation was issued in the amount of $250.

Exit interview conducted, today's reports and appeal rights were reviewed and issued to Executive Director.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 03/30/2023 04:22 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/30/2023 at 02:19 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: 03/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2023
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Executive Director locked the cabinet and ensured that all accessible items were secured during today's visit. Training will be provided to all staff on section 87705 and proof of training will be sent to CCL by 04/13/2023.
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Based on observation and record review, the licensee did not comply with the above cited section, as Glade Air Freshener, Windex wipes, and Oxi Clean spray were observed in resident's room with an open door, accessible to residents which poses an immediate safety risk to residents in care.
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Type B
03/31/2023
Section Cited
CCR87211(a)(1)(D)

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87211 (a)(1) (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Executive Director agreed to submit incident reports to CCL and Regional Center by close of business on 03/31/2023.
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Based on interview and record review, the licensee did not comply with the above cited section as 4 incidents which occurred between 03/02/2023 and 03/06/2023 were not reported to CCL timely, which poses a potential safety and personal rights risk to residents 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:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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