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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/15/2024
Date Signed: 11/01/2024 04:34:31 PM

Document Has Been Signed on 11/01/2024 04:34 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR/
DIRECTOR:		GARY Y LEEFACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 16DATE:
10/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Roman TovarTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding a self-reported incident which occurred at the facility on or about 9/29/2024. LPA met with administrator Roman Tovar and assistant administrator Leticia Hernandez and explained the reason for the visit. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Katy Robison.

LPA and QAS first met with the assistant administrator and requested pertinent documents. LPA and QAS conducted interviews with staff and resident 1 (R1) starting at 1:42 p.m. There were more staff LPA and QAS needed to interview but they were not at the facility. LPA will return at a later date to complete the investigation.

It had been reported that on 9/29/2024, R1 reported to staff they were handled roughly by staff 1 (S1). This was reported to Community Care Licensing (CCL) on 10/9/2024. The facility conducted their own internal investigation and shared the information they obtained.

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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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 11/01/2024 04:34 PM - It Cannot Be Edited


Created By: Teresa Camara On 10/15/2024 at 04:14 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: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2024
Section Cited
CCR
87211(c)

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87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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Licensee will provide a written understanding of reporting requirements to CCL on or before 10/22/2024.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited as licensee waited 10 days to report this incident, 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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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