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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/26/2023
Date Signed: 10/26/2023 10:32:04 AM

Document Has Been Signed on 10/26/2023 10:32 AM - 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 N.ASC, 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:
10/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gary LeeTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Administrator Gary Lee and informed them of the reason for the visit. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 10/18/2023.

The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 10/17/2023 regarding one Resident #1 (R1), and two staff (S1, S2). It was reported that after R1 was criticizing S1, S1 was witnessed by S2 throwing a diaper at R1, saying to R1 they were not going to help anymore, and loudly saying "Retarded People" as they were walking away. It was further reported S1 was suspended.

During today's inspection, the LPA obtained pertinent documents and interviewed S1 (via phone call), R1 and the administrator. Staff and resident interviews revealed that the incident did occur, however S1 stated the diaper was thrown at S2 and that they stated "you are retarded" to S2. S1 acknowledges they should not be speaking in that manner to or in front of the residents.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC809-D).
Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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 10/26/2023 10:32 AM - It Cannot Be Edited


Created By: Esther Cortez On 10/26/2023 at 10:09 AM
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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
87468.1(a)(1)

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87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirment was not met as evidence by:
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Administrator suspended S1, and has agreed to review with staff (S1)the regulation 87468.1 (a)(1)-and send proof or self-verification via a letter to the CCLD department by 11/02/2023.
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Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) spoke inappropiately and threw a diaper which posed a potential 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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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