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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 08/01/2023
Date Signed: 08/01/2023 03:45:07 PM

Document Has Been Signed on 08/01/2023 03:45 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:
08/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Gary Lee TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cotez conducted an unannounced Case Management – Incident inspection pertaining to a self-reported Special Incident Report (SIR) received on 07/31/2023. The LPA met with Executive Director Gary Lee at 09:25 AM and informed them the reason for the visit.

The self-reported SIR pertains to a medication error that occurred on 07/27/2023. Upon further file review the LPA received various self-reported SIRs regarding medication errors involving various residents for the months of April (4), June (1) and July (11), as a reoccurring issue. Medications errors include missed medications and high blood sugars for various residents. On 4/25/2023 the LPA spoke to Executive Director Gary, and they stated that all MedTech’s were going to complete in service training checking that medications were being passed all three times. The ED was not able to produce verification of the in- service training.

During today's inspection, at 10:12 a.m. the LPA obtained pertinent documents and reviewed the following Special Incident Reports with Executive Director Gary and Assistant Administrator Leticia Hernandez:

07/15/2023, 7/23-7/25/23: Resident 1 (R1) Missed Medication
07/17/2023, 7/22/2023: Resident 2 (R2) Missed Medication
7/22/2023 Resident 3 (R3) Missed Medication
7/23/2023 Resident 4 (R4) High Blood Sugar
7/24/2023, 7/26-27/23 Resident 5 (R5) High Blood Sugar
7/27/2023 Resident 6 (R6) Missed Medications



REPORT WILL CONTINUE ON LIC809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/01/2023 03:45 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/01/2023 at 12:05 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: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Executive Director agress they will:
1. Do a medication audit for all residents to assure no other medications have been missed by 8/2/23 and submit proof to CCL.
2.have all staff complete a medication training by 8/4/23 and diabetes (diet) by 8/11/23 & submit proof.
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Based on interview and record review, the licensee did not comply in the section cited above for four out of fifteen residents (R1, R2, R3,R6), due to missed medications, which poses an immediate health and safety 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:Desaree Perera
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 08/01/2023
NARRATIVE
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Executive Director Gary indicated that missed medications errors occurred due to staff not paying attention, and possibly due to residents having too many medications and staff getting confused. The LPA advised the ED, that staff should be trained on handling residents medications. He continued to state that even though different Med technicians have been making errors, a lot of the missed medications have been made by their new staff (S1). The ED stated that they hired S1 due to having a lot of experience, but he thinks S1 brought a lot of bad habits and will be requiring more in service training on medication as well as shadowing. Both the ED and Assistant Administrator Leticia Hernandez stated that staff is not trained on how to care for residents with Diabetes.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were 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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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