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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:09:58 PM

Document Has Been Signed on 07/28/2023 03:09 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:
07/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Gary LeeTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management – Deficiencies visit in conjunction with complaint control # 29-AS-20230406155619.

Upon entry into the facility, the LPA observed that the front door was equipped with delayed egress. Per the fire clearance granted by the Department on 8/10/2021, delayed egress for this location was not approved. An interview with Executive Director Gary Lee confirmed that there are four (4) doors (including the front door) equipped with delayed egress. It was communicated that the delayed egress mechanism is not activated; however, all of the doors were alarmed. Executive Director G. Lee indicated they had not submitted any paperwork to the department yet, as they were informed that they would need to obtain approval from the fire department prior to sending paperwork to the department. Per Executive Director G. Lee, the fire department came out and did a walk-through in May 2023, and indicated that the facility was not approved for delayed egress at that time. The Executive Director indicated that the facility was still in the process of making corrections for the delayed egress to be approved. The LPA tested the four exterior doors at 12:23 p.m., 12:26 p.m., 12:27 p.m., and 12:29 p.m., and observed that the egress mechanism was not engaged, and the LPA was able to egress out of the door without delay.

The LPA was unable to identify any documentation to determine that the licensee informed the Department of the installation of the delayed egress doors. Executive Director Lee indicated that the mechanisms had been installed on the doors for some time.

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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 07/28/2023 03:09 PM - It Cannot Be Edited


Created By: Ashley Smith On 07/28/2023 at 02:36 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: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
87705(k)(1)

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87705(k)(1) Care of Persons with Dementia. The following ...must be met for the licensee to utilize delayed egress devices ... (1) The licensee shall notify the licensing agency immediately after determining the date that the device will be installed.
This requirement is not met as evidenced by:
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The Executive Director agreed to the following:
1. Submit a statement of understanding, certifying that the community is unable to and will not engage the delayed egress mechanisms until they obtain the appropriate fire clearance.
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Based on observation and interview, the licensee did not comply in the section cited above, as the licensee installed delayed egress doors without notifying the department, which poses an immediate personal rights risk to residents in care.
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Statement must be submitted by 7/31/2023

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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023


LIC809 (FAS) - (06/04)
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