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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850221
Report Date: 10/04/2024
Date Signed: 10/04/2024 05:17:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240313134850
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: 16DATE:
10/04/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Roman Sierra TobarTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff unlawfully evicted a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Roman Sierra Tobar and was explained the reason for the visit.

On 03/14/2024, between 11:30 a.m. and 4:00 p.m., the LPA toured the facility with staff, interviewed the Administrator, two (2) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/07/2024, between 11:30 a.m. and 4:30 p.m., the LPA toured the facility with staff, interviewed the Administrator, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/08/2024, between 10:55 a.m. and 11:55 a.m., the LPA interviewed two staff and obtained pertinent documents relevant to the investigation. During today's visit the LPA conducted a file review and one (1) staff and one (1) witness phone interview between 2:00 p.m. and 4:30 p.m.

Report will continue on LIC9099-C 2nd page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/04/2024
NARRATIVE
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On the allegation " Staff unlawfully evicted a resident"; it is the concern of the reporting party that Resident #1 (R1) was unlawfully evicted from the facility without any kind of eviction notice. To investigate the allegation the LPA conducted a file review and interviews. File review revealed that the Executive Director did not obtaining prior written eviction approval from the licensing and did not issue an eviction notice to R1 and or their responsible party. Interviews with the previous Executive Director, Gary Lee revealed that on 02/20/2024, R1 was observed with what they thought to be a stage 3 wound, and stated R1 could not be at the facility with a stage 3 wound. They went on to state that R1’s family had home health assess the resident and they confirmed it was a stage 3. The ED discussed with R1’s family possibilities to place R1 on hospice, however after the ED discussed with their director what was going on, the director did not allow for R1 to stay at the facility, according to the ED. Furthermore, the ED revealed that they did not obtained a prior written approval from licensing because everything happened so fast and R1’s responsible person wanted R1 out of the facility right away. Interview with R1’s responsible party revealed that they were not given a 3 day or 30 day notice and were told that R1 could not be at the facility, despite their attempts to place R1 on home health and hospice to ensure that R1 could stay. Based on records reviewed and interviews conducted, it has been determined that Executive Director did not submit a proper letter of eviction to CCL, nor did Executive Director provide Responsible Party with a proper letter of eviction. Therefore, the allegation that Staff unlawfully evicted a resident is Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. ED was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240313134850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 OJAI
FACILITY NUMBER: 565850221
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2024
Section Cited
CCR
87224(a-b)
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87224(a)The licensee may evict a resident... Thirty (30) days written notice to the resident is required ..(b) upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. ...This regulation is not met as evidenced by:
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Executive Director agrees to read and review Regulation 87224 Evictions Procedures and submit a letter of undestanding, and train all staff that provide notices on the proper way to evict residents in care and provide proof to CCL by 10/05/2024.
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Based on interviews and record review, the ED did not ensure that they provided R1 and/or their responsible person with a proper eviction notice and did not get prior approval from licensing, which posed an immediate health and safety risk to resident(s) 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4