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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:48:24 PM

Document Has Been Signed on 05/12/2023 12:48 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: 14DATE:
05/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gary LeeTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek, along with Tri-Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett conducted an unannounced Case Management – Incident visit for the purpose of following up on self-reported incidents. LPA and QA met with Administrator Gary Lee. Entrance interview conducted.

The Woodland Hills Regional Office received 3 (three) self-reported incidents, 2 (two) of which occurred on 04/29/2023 and one occurred on 04/30/2023. The incidents on 04/29/2023 were related to Staff #1(S1) and food service. The third incident involved Staff #2 (S2) allegedly grabbing Resident #1 (R1's) face.

During today's visit, LPA, QA, and Administrator toured the facility at 10:43AM, interviewed Administrator at 10:25AM, and interviewed staff at 10:53AM, 11:04AM, and 11:38AM. Previously, Tri Counties Regional Center Service Coordinator interviewed R1. Interview with R1 revealed that they feel safe and could not recall any incident involving S2. When the witness was interviewed, they also did not immediately recall any incident involving S2, however when prompted, did indicate they saw S2 touch R1's face, but did not feel it was malicious nor rose to the level of abuse. Administrator indicated both S1 and S2 received formal write ups for the reported incidents and retraining will be completed with all staff. No health and safety concerns were identified during today's visit.

No citations issued during today's visit. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023
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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