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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 10/15/2025
Date Signed: 10/15/2025 03:28:09 PM

Document Has Been Signed on 10/15/2025 03:28 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: 15DATE:
10/15/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Rafael Silva/AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/14/2025. The LPA met with Administrator Rafael Silva and explained the reason for the visit.

The LPA conducted a tour of the physical plant with Administrator Rafael Silva to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double story residence, with the second story only for staff use. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/23/2025. The smoke alarms and carbon monoxide detectors were tested and functioned properly.

KITCHEN: The kitchen is left locked so residents cannot enter. The kitchen was clean and the appliances appeared to be functional The facility's main pantry is air conditioned and located outside. The pantry had non-perishable foods, perishable foods, and three large freezers with perishable foods. Food was also stored in the kitchen and another pantry inside the facility which had more non-perishable food and emergency water.
RESIDENT ROOMS: There are currently sixteen rooms available for residents of which ten (10) are being used by residents; these rooms can be shared or can be single rooms. There are two (2) rooms being used as model rooms and one (1) as an activity room. There are six rooms upstairs which are used as office space, staff rooms, and storage. The upstairs rooms can only be accessed by stairs so they are not in use for residents at this time. Rooms housing residents appeared to be clean with appropriate furnishings, bedding and sufficient lighting, however floors needed to be swept. Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 10/15/2025
NARRATIVE
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BATHROOMS: The facility has two shower rooms of which the toilet in one of the shower rooms is not working. Upon observation Administrator stated they would be fixing it by tomorrow 10/16/25. Four resident rooms have full bathrooms. The facility has eleven half bathrooms; some are private and others are "jack and jill" bathrooms between two rooms. Bathrooms appeared to be clean and had grab bars, however floors needed to be swept and mopped. The shower rooms had non-skid mats. Water temperature measured in four (4) restrooms ranged between 109.2 degrees Fahrenheit and 124 degrees Fahrenheit. Upon observation the Administrator adjusted the hot water temperature in the bathroom between bedroom 13 and 14 that measured 124 F and new water temperature measured at 113.6 degrees Fahrenheit.

OUTDOOR: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water were observed.

Interviews: The LPA conducted four (4) resident and two (2) staff interviews. No concerns were voiced.

Medication Audit: The LPA conducted Medications audit for three (3) residents. The medications are locked in medication carts. Medications are labeled and checked for expiration dates. Medications were observed to not be properly documented on the centrally stored medications and destruction record (CSMDR) as the facility receives a pre-filled CSMDR from the pharmacy however start dates, expiration dates and number of refills for many medications were either not documented or documented incorrectly by the pharmacy. LPA and Med Tech discussed best practices of reviewing and correcting the CSMDR. During Resident 1's (R1's) audit the LPA observed one morning medication was not given on 10/09/25. Additionally, during R2's audit the LPA observed seven (7) morning medications were not given on 10/9/25. Upon observation staff stated that the MT (MT1) on 10/09/25 did not realize both residents had already left for Day Program and did not give them their morning medication.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/15/2025 03:28 PM - It Cannot Be Edited


Created By: Esther Cortez On 10/15/2025 at 03:00 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: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 residents that were not administered their morning medications on 10/09/25 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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Administrator stated they will be providing MedTech that did not provide the medication with additionall medication training and provide proof to LPA by 10/21/25
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2025 03:28 PM - It Cannot Be Edited


Created By: Esther Cortez On 10/15/2025 at 03:00 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: 10/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one of four restrooms that hot water temperature measued at 124 degrees F which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2025
Plan of Correction
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POC CLeared, water tempearute was adjusted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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