MANOR OF OJAI, THE

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 Based on water temperature tested over 102*(f), the licensee did not comply with the section cited above as identified which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction Licensee agrees to have plumber address water temperature in the North West side of facility. Licensee will text picture by cell LPA Jeffies, daily water temperature one week and a last reading on day 14 that shows water reading in regulation perimeters.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by: The Licensee did not comply with the section cited above as 7 out of 13 residents un covered toothbrushes were stored together, in a supply room whith cleaning supplies and bristles touching, which poses a potential safety risk to clients in care.

Official plan of correction

Licensee agreed to replace all 7 toothbrushes with new ones, and store them in a sanitary manner. Will submit proof to LPA no later than 2/13/2025.

Deadline recorded: Feb 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in count 1 of 1 [which dementia information was not in the plan of operation or on the facility license while accepting resident with dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee will submit an addendum to the facility plan of operations including dementia care that the facility will conduct on normal operations. licensee will email addendum and request to assigned LPA and will follow up with daily duty officer and or designated LPA as needed until addendum is approved.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited aboveas for four staff (S1, S3, S4, S5) need a health screening and two staff (S1,S5) need TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction The Administrator has agreed to do the following: 1. Ensure all staff obtain health screeninng with TB test and submit proof to the LPA no later than 1/12/2024.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as three staff (S3, S4, S5) did not have a criminal record statement LIC508 on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction S3 is currently out of the country and not working at the facility, the Administrator agreed to obtain LIC508 for S4 and S5 and submit proof to the LPA no later than 1/12/2024.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as five out of five staff were missing 40 hours of training in the required topics wich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction The Administrator has agreed to ensure all staff receive required training and submit proof to LPA by no later than 1/12/2024.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as one resident (R2) does not have TB results on file iwhich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction The adminsitrator agreed to the following: 1. Ensure that R2 completes TB testing and provide proof of results to LPA no later than POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as three out of five residents (R2, R4, R5) were missing appraisal/needs and services plans which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction The adminsitrator agreed to the following: 1. Ensure to complete the appraisal/needs and service plan for R2,R4 and R5 and submit proof to the LPA by 1/12/2024.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as one out five residents admission agreement was not signed by resident and/or residents responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction The adminsitrator agreed to the following: 1. Ensure that R2's admission agreement is signed by R2 and/or responsible party and submit proof to the LPA by 1/12/24.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as fifteen (15) food items in the food pantry were expired which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction Licensee agrees to complete a food audit to ensure all food is of good quality and discard all expired food items. Complete audit by the end of day on 6/3/2023 and informed CCL when audit is complete not later than the POC due date.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the LPAs observed pliers accessible to the residents., which poses an immediate health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The licensee agrees to secure and lock all tools to ensure all items listed above are inaccessible to the residents. Complete and submit proof to CCL by the POC due date. Proof can be photos or a self certification.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the LPAs observe shovels, fertilizer, rakes, gardening supplies, and soil in the courtyard accessible to the residents, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The licensee agrees to secure and lock all tools to ensure all items listed above are inaccessible to the residents. Complete and submit proof to CCL by the POC due date. Proof can be photos or a self certification.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to ...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 Based on observation, the licensee did not comply with the section cited above in as the water temperature in resident bathrooms up to 137.8 degrees F which poses an immediate health and safety risk to persons in care

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction Staff adjusted the water temperature during the visit. The administrator shall complete a 5-day water temperature log which indicates the water temperature is within the required range of 105-120 degrees and submit proof to CCL by 06/28/2022.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided proper care and supervision which resulted in R1 sustaining a stage III wound to shoulder infested with ants, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan to ensure proper care and supervision is being provided to the residents. Submit to CCL by 12/02/2022.

Deadline recorded: Dec 2, 2022. A deadline is not proof that correction was completed.