Artesian Of Ojai, The is a residential care home for the elderly (RCFE) in Ojai, Ventura County, California — state license #567609954, with a licensed capacity of 72, listed as closed, change of ownership in the CDSS record we retrieved August 2, 2026. It does not appear on the DHCS Assisted Living Waiver participant list checked August 9, 2026 — that list covers the state waiver only, not a home's own payment arrangements. California has 39 dated inspection and complaint documents on file for this home going back to 2021, the most recent dated February 17, 2026 — published below in full, verbatim and unscored.

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Artesian Of Ojai, The

The state record lists this licence as “Closed, Change of Ownership”. A closed licence cannot admit residents. We keep closed licences published because “is this place licensed?” deserves an honest answer.

The state also licenses a home at this address today: Artesian Of Ojai The · licence #565850442

No photo on file yet

No photo of this home is on file — we show real, attributed images only, never a stock photo of someone else’s building.

Residential care home for the elderly (RCFE) · Large community, 72 residents · Ojai, CA · Ventura County
Closed in state recordWheelchairMemory careHospiceBedridden not on file
No openings reportedBeds change hands in days · we confirm by phone before any referral
License #567609954, held since 2020 · read from the California state record on August 2, 2026 ·See on State Site →
203 E El Roblar Drive · Ojai, Ventura County
Phone
(805) 798-9305
from the state licensing roster · August 2, 2026
No Google listing is on file for this home.
Website
None on file
Many small homes have no website — that says nothing about the care inside.
Contact facts come from the state roster, a county Area Agency on Aging roster, the home’s Google listing, or the operator — each labelled, never blended. Operators: add or correct yours, free →

Wheelchair / non-ambulatoryApproved for 72 residents
Dementia / memory careVerified in record
Hospice careApproved for 15 residents
Bedridden careNot on file — ask the home

“Not on file” is not a no — approvals can be bed- or room-specific, so confirm current scope with the home on a tour. Where a number is shown it is the state’s own wording for how many residents the approval covers, not how many places are open today; where none is shown, the record simply does not state one.

Specific medical needs — insulin, oxygen, a catheter, an ostomy — aren’t in the state license record; ask the home directly. A feeding tube, tracheostomy, or advanced wound care usually needs skilled nursing →

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What the state record says, word for word
72 NON-AMBULATORY. HOSPICE WAIVER FOR 15. DELAYED EGRESS APPROVED IN BUILDINGS 3 AND 4.State service designation983 - RCFE / DEMENTIAthe CDSS license record, verbatim · checked August 2, 2026

“RCFE / Dementia” is the state’s designation for a home with an approved Dementia Care Plan of Operation — it’s recorded separately from the comments above, which is why the memory-care approval may not appear in that text.

Since 2021, the state has visited this home 50 times and filed 39 documents. The most recent is a complaint investigation report, dated February 17, 2026.

Most recent state visit
March 9, 2026
Occupancy at the August 25, 2025 visit
36 of 72 beds

The state's published file for this home includes 24 documents with transcribed findings, dated July 12, 2021 to August 25, 2025. 24 of the 24 carry the state's recorded outcome word: “Substantiated” (21), “Unsubstantiated” (3). 24 include the transcribed allegation the state investigated, word for word.

Summary composed by computer from the 24 documents below — every count derives from them, and the documents themselves are the state's records, verbatim. We never grade, score, or color a record.

What the state’s words mean
Substantiatedthe state found the allegation more likely true than notUnsubstantiatedinvestigated, but couldn’t be confirmed either way — not a finding of wrongdoingUnfoundedthe state concluded it was false or couldn’t have happenedType A citationthe most serious: an immediate health-or-safety risk, usually fixed on the spot or on a short deadlineType B citationless serious, with a deadline to fix
The last 36 months — 19 of 39 documentsFull record on the state’s site →
20262 state visits · 2 documents
Feb 17, 2026Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jan 15, 2026Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

20255 state visits · 7 documents
Sep 19, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Aug 25, 2025Complaint investigation reportSubstantiated

Allegation investigated: Emergency cords are not accessible to residents.

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a 10 Day complaint visit. Upon arrival, the LPA met with Memory Care Director Iris Perez and Business Office Manager Melanie Lopez for Care Field and the reason for the visit was explained. Entrance interview conducted. During today's visit the LPA toured the facility with the Memory Care Director, conducted interviews with five (5) staff, conducted interviews with three (3) residents and attempted to interview two additional residents, and observed med pass for five (5) residents. Report will continue on the following page LIC9099-C, 2nd page. Substantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2025 · control 29-AS-20250820161847
Aug 25, 2025Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jul 16, 2025Complaint investigation reportSubstantiated

Allegation investigated: Licensee does not ensure staff have proper fingerprint clearances Staff are not dispensing medications as prescribed.

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted a subsequent complaint investigation visit regarding the above noted allegations. LPAs met with Marketing Director Andrea Davis who is a designated facility representative (Designee) and explained the reason for the visit. At 2:14 p.m. LPA Dulek reviewed staff files and found that Staff 1 (S1) has a fingerprint clearance with an exemption, however S1 is not associated to this facility. S1 was hired in April 2025. At 3:21 p.m. LPA Camara conducted a medication audit and found most of the medications reviewed appeared to be given as prescribed. However, Resident 1 (R1) and Resident 2 (R2) both had medications in bubble packs that appeared to not be given as prescribed, likely due to a documentation error. LPA also observed the start dates for medications were not consistently noted on the Centrally Stored Medication and Destruction Records. Based on records reviewed, the above noted allegations are deemed SUBSTANTIthe state’s words, verbatim · CDSS document, Jul 16, 2025 · control 29-AS-20250514132340
Jul 16, 2025Complaint investigation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Apr 4, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 28, 2025Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

20246 state visits · 7 documents
Oct 1, 2024Complaint investigation reportSubstantiated

Allegation investigated: Facility overcharged resident

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with facility staff who informed the LPA that Executive Director Amber Winterstein is no longer with the Artesian of Ojai. The LPA met with facility representative Michael Weyrick and was explained the reason for the visit. On 04/02/2024,between 12:30 p.m. and 4:30 p.m., the LPA interviewed the Care director, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/26/2024, the LPA conducted a file review, and interviewed the Executive Director. On 10/01/2024 at 10:13 a.m. LPA conducted a phone interview with one (1) staff. During today's visit the LPA conducted two (2) staff interviews, interview with R1's authorized person and obtained pertinent documents revelant to the investigation. Report will continue on LIC9099-C-2nd page. Substantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 29-AS-20240325114827
Aug 9, 2024Complaint investigation reportSubstantiated

Allegation investigated: Licensee fails to make reasonable efforts to safeguard residents property

At 12:10 p.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit at the facility today. The LPA met with Administrator Amber Winterstein and explained the reason for the visit. On 11/20/2023, at 1:58 p.m., LPAs Emily Peraldi and Elsie Campos conducted an interview with the Administrator. At 2:06 p.m., the LPAs obtained copies of pertinent documents. At 2:55 p.m., the LPAs along with the Administrator conducted a physical plant tour. During today's visit, LPA Cortez conducted a file review, interviewed the Administrator and three (3) staff. On the allegation that Licensee fails to make reasonable efforts to safeguard residents’ property; it is the concern of the reporting party that several items, including a purple vase with an estimated value of $250-$300, Bath, kitchen and hand towels, large emery board, box of gloves, and a container of wipes went missing from Resident’s #1 (R1’s) room. Report will continue on LIC9099-C. Substantiatedthe state’s words, verbatim · CDSS document, Aug 9, 2024 · control 29-AS-20231113165608
Aug 8, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Jul 30, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Mar 8, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Mar 8, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Feb 2, 2024Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

20233 state visits · 3 documents
Nov 20, 2023Facility evaluation reportReport on file

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Oct 20, 2023Complaint investigation reportSubstantiated

Allegation investigated: Facility refuses to provide resident records and incident reports to residents responsible party (RP) Resident incident reports are not being reported to RP and Licensing Staff is not trained properly in dementia resident care and transfers

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility at 09:00 a.m. The LPA was greeted by staff and the reason for the visit was explained. Administrator Amber Winterstein arrived shortly after. Today, the LPA conducted one (1) resident, four (4) staff interviews, interviewed the administrator throughout the visit, and obtained pertinent copies between 9:00 a.m. and 5:00 p.m. On the allegation that Facility refuses to provide resident records and incident reports to resident’s responsible party, it is the reporting party’s concern that the responsible party for one resident (R1) requested copies of incident reports, information on resident falls, physicians report from the hospital and did not receive any documents. Report will continue on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 29-AS-20231003143814
Sep 5, 2023Complaint investigation reportSubstantiated

Allegation investigated: Staff do not assist with the self-administration of resident's medications as prescribed. Facility staff do not respond to resident’s call button.

This is an amended report. Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit on 09/05/2023 to issue final findings for the allegations above. LPA arrived at the facility and announced the purpose of the visit. LPA met with Amber Winterstein, Administrator of the facility. On the allegation: Staff do not assist with the self-administration of resident's medications as prescribed. It was alleged that the pharmacy providing the medications to the facility for residents was unable to fill a specific medication due to pharmacy hours and weekend schedule. The allegation states that facility staff were not sensitive to the pain this would cause in a resident without their medication. On 08/17/2023, LPA received documentation about R1’s medications including the Medication Administrative Report (MAR) and the Centrally Stored Medication & Destruction Log. Continued on 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Sep 5, 2023 · control 29-AS-20230407163919
Beside homes the same size
Type A citations17typical 1
Type B citations19typical 1
Substantiated complaints46typical 2
Total complaints22typical 7
State visits on file50typical 19
“Typical” is the statewide median across the 1,244 licensed larger communities (16+ beds) in the state record — larger, longer-licensed homes accumulate more visits and reports, so compare like with like. One complaint can contain several allegations. Counts cover this license since 2020.
Year-by-year trend
YearVisitsDocumentsSubstantiated20262202025572202467220238151220226632021562
An “unsubstantiated” complaint is not a finding of wrongdoing — it means the state investigated and could not confirm the allegation. Outcome words are the state’s own; we never grade, score, or color a record.Operate this home? Respond to or correct any document here, free. Respond or correct →

See an error in these counts? Report it — free →

$5,000$7,500 /mo
our estimate — Ventura County band, market research June 2026; not this home’s quoted price
$3,500 · statewide low$9,000 · statewide high
California’s public record holds no per-home price, so we never invent one.
Ways families pay here
Private pay — ask what the base rate includes and what’s billed separately.SSI/SSP — California’s board-and-care payment standard is $1,626.07/mo (2026): $1,444.07 to the home, $182 stays with the resident.Medi-Cal ALW — this home isn’t on the DHCS waiver list (checked August 9, 2026). Details →

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Is Artesian Of Ojai, The licensed?

No — not currently. The CDSS state record checked August 2, 2026 lists Artesian Of Ojai, The in Ojai (Ventura County), California license #567609954, as “Closed, Change Of Ownership, formerly licensed for 72 residents. State records list 39 inspection and complaint documents since 2021; the most recent, a complaint investigation report dated February 17, 2026, appears in the inspection record on this page.

Can Artesian Of Ojai, The care for dementia, hospice, bedridden, or non-ambulatory residents?

From the CDSS license record, checked August 2, 2026.

The CDSS license record checked August 2, 2026 lists Artesian Of Ojai, The with clearances for wheelchair / non-ambulatory, dementia / memory care, and hospice care; it does not list bedridden. A clearance that is not on file is not a “no” — it may simply be unrecorded, so if your family needs one of these, ask the home directly and confirm its current scope on a tour.

Wheelchair / non-ambulatoryDementia / memory careHospice careBedridden

From the California state record. Some approvals are bed- or room-specific — always confirm current scope with the facility.

What the state record says, word for word
Verbatim, from the CDSS license record72 NON-AMBULATORY. HOSPICE WAIVER FOR 15. DELAYED EGRESS APPROVED IN BUILDINGS 3 AND 4.

How much does Artesian Of Ojai, The cost?

California's public licensing record does not include Artesian Of Ojai, The's monthly price, so we never show or estimate one for a specific home. As county-level context only, assisted living in Ventura County typically runs $5,000–$7,500/mo and small board-and-care homes $4,000–$6,500/mo (market research compiled June 2026 — ranges, not quotes; California's 2026 SSI/SSP board-and-care payment standard is $1,626.07/month, of which $1,444.07 is the room-and-board portion paid to the home). Ask the home for its own rate sheet and what the base rate includes — or use the cost section at the top of this page.

Does Artesian Of Ojai, The accept Medi-Cal or the Assisted Living Waiver?

Artesian Of Ojai, The is not in the DHCS Assisted Living Waiver participant record we checked August 9, 2026 — that list covers only the state's ALW program, not a home's own payment policies, so ask the home directly about private Medi-Cal arrangements. The waiver pays for assisted-living care services (not room and board) at participating homes; every DHCS-listed home appears on our statewide Medi-Cal page.

Assisted living on Medi-Cal in California →See the DHCS list →

How full it was at the last state visit

36 of 72 beds occupied (50%) when the state visited on August 25, 2025. Availability changes constantly — confirm a current opening with the home.

What do state inspections show for Artesian Of Ojai, The?

Verbatim from CDSS complaint-investigation reports — the state's own words, never summarized by us. Record checked August 2, 2026.

The CDSS state record checked August 2, 2026 lists 50 state visits and 39 dated documents since 2021 for Artesian Of Ojai, The; 24 complaint-investigation narratives are transcribed verbatim below. The most recent, dated August 25, 2025, records an allegation the state marked “Substantiated. Open any entry to read the state's full finding, word for word.

Most licensed homes receive some findings over 36 months; what matters is what was found and whether it was corrected. Counts here are shown compared with homes of similar size, and the state's own words appear in full below.

24 transcribed reports on file

2025

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedEmergency cords are not accessible to residents.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a 10 Day complaint visit. Upon arrival, the LPA met with Memory Care Director Iris Perez and Business Office Manager Melanie Lopez for Care Field and the reason for the visit was explained. Entrance interview conducted. During today's visit the LPA toured the facility with the Memory Care Director, conducted interviews with five (5) staff, conducted interviews with three (3) residents and attempted to interview two additional residents, and observed med pass for five (5) residents. Report will continue on the following page LIC9099-C, 2nd page. SubstantiatedCDSS inspection report, August 25, 2025 · control 29-AS-20250820161847
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedLicensee does not ensure staff have proper fingerprint clearances Staff are not dispensing medications as prescribed.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted a subsequent complaint investigation visit regarding the above noted allegations. LPAs met with Marketing Director Andrea Davis who is a designated facility representative (Designee) and explained the reason for the visit. At 2:14 p.m. LPA Dulek reviewed staff files and found that Staff 1 (S1) has a fingerprint clearance with an exemption, however S1 is not associated to this facility. S1 was hired in April 2025. At 3:21 p.m. LPA Camara conducted a medication audit and found most of the medications reviewed appeared to be given as prescribed. However, Resident 1 (R1) and Resident 2 (R2) both had medications in bubble packs that appeared to not be given as prescribed, likely due to a documentation error. LPA also observed the start dates for medications were not consistently noted on the Centrally Stored Medication and Destruction Records. Based on records reviewed, the above noted allegations are deemed SUBSTANTICDSS inspection report, July 16, 2025 · control 29-AS-20250514132340

2024

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility overcharged resident
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with facility staff who informed the LPA that Executive Director Amber Winterstein is no longer with the Artesian of Ojai. The LPA met with facility representative Michael Weyrick and was explained the reason for the visit. On 04/02/2024,between 12:30 p.m. and 4:30 p.m., the LPA interviewed the Care director, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 08/26/2024, the LPA conducted a file review, and interviewed the Executive Director. On 10/01/2024 at 10:13 a.m. LPA conducted a phone interview with one (1) staff. During today's visit the LPA conducted two (2) staff interviews, interview with R1's authorized person and obtained pertinent documents revelant to the investigation. Report will continue on LIC9099-C-2nd page. SubstantiatedCDSS inspection report, October 1, 2024 · control 29-AS-20240325114827
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedLicensee fails to make reasonable efforts to safeguard residents property
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
At 12:10 p.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent complaint visit at the facility today. The LPA met with Administrator Amber Winterstein and explained the reason for the visit. On 11/20/2023, at 1:58 p.m., LPAs Emily Peraldi and Elsie Campos conducted an interview with the Administrator. At 2:06 p.m., the LPAs obtained copies of pertinent documents. At 2:55 p.m., the LPAs along with the Administrator conducted a physical plant tour. During today's visit, LPA Cortez conducted a file review, interviewed the Administrator and three (3) staff. On the allegation that Licensee fails to make reasonable efforts to safeguard residents’ property; it is the concern of the reporting party that several items, including a purple vase with an estimated value of $250-$300, Bath, kitchen and hand towels, large emery board, box of gloves, and a container of wipes went missing from Resident’s #1 (R1’s) room. Report will continue on LIC9099-C. SubstantiatedCDSS inspection report, August 9, 2024 · control 29-AS-20231113165608

2023

Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility refuses to provide resident records and incident reports to residents responsible party (RP) Resident incident reports are not being reported to RP and Licensing Staff is not trained properly in dementia resident care and transfers
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility at 09:00 a.m. The LPA was greeted by staff and the reason for the visit was explained. Administrator Amber Winterstein arrived shortly after. Today, the LPA conducted one (1) resident, four (4) staff interviews, interviewed the administrator throughout the visit, and obtained pertinent copies between 9:00 a.m. and 5:00 p.m. On the allegation that Facility refuses to provide resident records and incident reports to resident’s responsible party, it is the reporting party’s concern that the responsible party for one resident (R1) requested copies of incident reports, information on resident falls, physicians report from the hospital and did not receive any documents. Report will continue on LIC9099-C SubstantiatedCDSS inspection report, October 20, 2023 · control 29-AS-20231003143814
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff do not assist with the self-administration of resident's medications as prescribed. Facility staff do not respond to resident’s call button.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
This is an amended report. Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit on 09/05/2023 to issue final findings for the allegations above. LPA arrived at the facility and announced the purpose of the visit. LPA met with Amber Winterstein, Administrator of the facility. On the allegation: Staff do not assist with the self-administration of resident's medications as prescribed. It was alleged that the pharmacy providing the medications to the facility for residents was unable to fill a specific medication due to pharmacy hours and weekend schedule. The allegation states that facility staff were not sensitive to the pain this would cause in a resident without their medication. On 08/17/2023, LPA received documentation about R1’s medications including the Medication Administrative Report (MAR) and the Centrally Stored Medication & Destruction Log. Continued on 9099-C SubstantiatedCDSS inspection report, September 5, 2023 · control 29-AS-20230407163919
Complaint investigationAllegation reviewed · Unsubstantiated
Allegation the state reviewedFacility staff did not safeguard residents’ belongings. Facility does not provide special diets to resident as prescribed. Facility staff did not assist with arranging transportation for resident. Facility staff did not assist with arranging residents’ medical appointments.
State's findingUnsubstantiatedThe state investigated but could not confirm the allegation. This is not a finding of wrongdoing.
This is an amended report. Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit on 07/05/2023 to issue final findings for the allegations above. LPA arrived at the facility and announced the purpose of the visit. LPA met with Mike O’Neill, Administrator. On the allegation: Facility staff did not safeguard residents’ belongings. It is alleged that staff members took a bag from a resident’s room containing cash and credit cards. The allegation states that upon return of the bag, cash was missing and $500 was spent from the resident’s debit account. On 04/13/2023, LPA obtained and reviewed the facility Plan of Operation regarding Handling of Client Money as well as the Personal Property/Theft and Loss Policy. The Plan of Operation states that the facility will not hold personal funds for residents and discourages the keeping of jewelry, documents, large sums of money, or other items considered to be of value on site. Continued on 9099-C UnsubsCDSS inspection report, July 5, 2023 · control 29-AS-20230407163919
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff is mishandling a resident's medication Resident is not being properly fed while in care
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Administrator Mike O’Neil and explained the purpose of the visit. LPA Angel Ascencio conducted the initial 10- day complaint visit on 10/19/2021 at 12:54 PM – 3:00 PM, LPA toured the facility inside and outside, conducted interviews with staff at 1:16 PM and 1:50 PM. interviews, obtained pertinent documents and reviewed resident files. LPA De Leon reviewed complaint, interviews and documentation collected. LPA De Leon interviewed Witnesses on 05/02/2023 at 3:30 PM and on 05/19/2023 at 1:07 PM. LPA De Leon requested and reviewed additional records on 05/19-05/21/2023. On the allegation: Staff is mishandling a resident's medication. LPA De Leon reviewed staff notes for Resident 1 (R1) which revealed on 07/21/2021 R1’s leg was swollen and was given Aleve for pain, leg continued to be swollen with pain for several days until R1 was finally taken out on 08/09/2021 and returnedCDSS inspection report, May 24, 2023 · control 29-AS-20211015125515
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedInsufficient staffing to meet residents needs. Staff mishandled resident medications. Incident was not reported to the authorized representative.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon made a subsequent complaint visit to the facility above to deliver final findings on the complaint investigation. LPA met with Mike O’Neil, Administrator and explained purpose of the visit. LPA Rosales conducted the initial complaint visit on 11/22/2021 from 10:09 AM – 3:10 PM, LPA toured the facility with the Administrator, interviewed random residents at 1:58 PM, 2:01 PM, 2:04 PM, 2:08 PM and staff at 1:11 PM, 1:28 PM, 1:37 PM, and 2:12 PM and obtained copies of pertinent documents. LPA De Leon reviewed complaint, records and interviews on 05/17/2023 and 05/18/2023. LPA De Leon requested additional records from facility 05/18/2023. On the allegation: Insufficient staffing to meet residents needs. LPA De Leon reviewed facility staffing schedules from 08/29/2021 – 11/06/2021 which revealed the facility had three buildings on the property called Matilija, Topa Topa, and Maricopa with a total resident census of 37. Continued 9099-C SubstantiatedCDSS inspection report, May 24, 2023 · control 29-AS-20211115100401
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff did not address a resident's change in medical condition resulting in hospitalization. Staff did not provide medical information to resident's responsible party in a timely manner. Staff did not seek medical attention in a timely manner.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Mike O’Neill and explained the purpose of the visit. LPA Dulek conducted the initial 10-day complaint visit on 12/20/2021 from 12:19 PM – 2:27 PM, interviewed staff at 12:36PM, toured the facility with Administrator at 12:54PM, reviewed files at 1:12PM, and gathered copies of pertinent documents. LPA Ascencio interviewed staff on 05/05/2022 at 2:50 PM. LPA De Leon interviewed witnesses on 05/02/2023 at 3:30 PM, 05/19/2023 at 1:07 PM, and 05/23/2023 at 12:18 PM. LPA De Leon requested additional documents on 05/18/2023, 05/22/2023 and 05/23/2023. LPA reviewed complaint, interviews and records on 05/18-05/24/2023. On the allegation: Staff did not address a resident's change in medical condition resulting in hospitalization. LPA reviewed facility staff notes which revealed Resident 1 (R1) was isolated at the facility fromCDSS inspection report, May 24, 2023 · control 29-AS-20211217142605
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedInsufficient staffing to meet residents needs Resident not being provided medical attention in a timely manner.
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Mike O’Neil Administrator and explained the purpose of the visit. LPA Rosales conducted the initial 10-day complaint visit on 10/05/2021 at 11:06 AM – 4:45 PM, toured facility, obtained pertinent documents and interviewed staff at 12:08 PM, 12:42 PM, 1:17 PM, 1:46 PM, 1:57 PM, 2:21 PM and interviewed residents at 2:48 PM, 2:53 PM, 2:58 PM, and 3:08 PM. LPA Rosales interviewed staff on 10/04/201 at 2:15pm. LPA Acenscio interviewed staff and witnesses on 08/02/2021. LPA reviewed interviews and documents from this complaint on 04/30/2023, 05/01/2023 and 05/02/2023. On the allegation: Insufficient staffing to meet residents needs. LPA De Leon reviewed staff schedules during 08/29/2021 - 10/02/2021 which revealed the facility had three buildings on the property called Topa Topa, Matilija, and Maricopa with a total resident census of 38. Topa Topa building was the memory care buCDSS inspection report, May 24, 2023 · control 29-AS-20210927103652
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedResident sustained pressure injuries while in care Insufficient staff to meet residents' needs
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint allegations. LPA met with the current Administrator Mike O’Neil and explained the purpose of the visit. LPA Dulek conducted the initial 10-day complaint visit on 06/07/2021 at 11:10 AM – 1:10 PM, LPA toured facility, conducted interview, reviewed resident records, and requested copies of pertinent documents. LPA Ascencio conducted a subsequent complaint visit on 08/25/2021 at 12:30 PM – 4:00 PM, toured inside and outside of the facility, toured 13 resident rooms and unsubstantiated the allegation “Facility not maintained clean and sanitary at all times”. LPA Ascencio conducted staff interviews on 08/25/2021 at 3:21 PM, 3:32 PM, 3:36 PM, on 05/05/2022 at 2:50 PM. LPA De Leon reviewed all documents collected and requested additional documents on 04/24/2023 and reviewed those documents on 04/26/2023. SubstantiatedCDSS inspection report, May 3, 2023 · control 29-AS-20210604105830
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff did not seek medical attention for resident in a timely manner
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent Complaint visit to the facility above to deliver final findings of the allegation. LPA met with the new Administrator Mike O’Neil and explained the purpose of the visit. LPA’s Rosales and Guzman-Chavez conducted the initial 10-day complaint visit at 10:04 AM – 3:57 PM, reviewed resident records, interviewed random staff and residents, and obtained copies of pertinent documents. Interviews were conducted with staff on 06/15/2021 at 11:40 AM, 12:01 PM, 12:41 PM, 1:28 PM, 1:41 PM, 1:55 PM, 2:00 PM, 2:18 PM, 2:33 PM, and resident interview at 11:33 AM. LPA received documentation on 06/07/2021 and 06/10/2021. LPA Rosales conducted staff interview on 10/04/2021 at 1:17 PM. LPA Rosales interviewed witness at 10:37 AM. LPA Rosales conducted a subsequent complaint visit on 10/05/2021 at 11:06 PM – 4:00 PM, toured facility with staff and interviewed with staff at 2:35 PM. LPA Deleon reviewed complaint, interviews, and documentation oCDSS inspection report, May 3, 2023 · control 29-AS-20210608163749
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff inappropriately spoke to (and in front of) residents in care. Staff did not obtain medication for resident on a timely basis. Staff allowed resident to have access to medications. Facility staff are not properly trained. Facility did not provide a comfortable environment for residents (inappropriate load music played by staff).
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the remaining complaint allegations. LPA met with Administrator Mike O’Neil and explained the purpose of the visit. LPA Rosales conducted the initial complaint investigation on 07/12/2021 at 3:30 PM – 7:21 PM, LPA Rosales interviewed staff at 3:30 PM, toured the facility with the Administrator, reviewed random resident medications/records, took 2 photographs, and obtained copies of pertinent documents. LPA Rosales conducted interviews on 04/09/2021 with Administrator at 8:34 AM, on 06/07/2021 at 2:21 PM with staff, on 06/15/2021 at 11:52 AM, 12:09 PM, and 12:53 PM with staff, on 07/12/2021 at 10:01 AM with witness, on 08/24/2021 at 9:22 AM with staff, on 10/04/2021 at 2:15 pm with staff, on 03/09/2022 at 9:22 AM and 9:37 AM with staff and on 03/10/2022 at 2:00 PM and 2:28 PM with staff. LPA De Leon reviewed interviews and documents on 04/30/2021 and requested additional documentsCDSS inspection report, May 3, 2023 · control 29-AS-20210707125403
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedStaff failed to meet the resident needs Staff curses in the presence of residents
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Administrator Mike O’Neil at 10:50 AM and explained the purpose of the visit. LPA Rosales conducted the initial Complaint visit on 04/09/2021 at 8:25am virtually toured the facility, conducted telephonic interviews with Administrator at 8:34 AM and requested copies of pertinent documents, interviewed additional staff at 9:13am. On 04/28/2021 an additional complaint was filed. On 04/30/2021 Administrator was interviewed at 2:23 PM and staff at 12:07 PM. On 04/09/2021 and on 05/07/2021 documents requested were received. SubstantiatedCDSS inspection report, April 17, 2023 · control 29-AS-20210401111205
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedInsufficient staffing Staff not reporting incidents to licensing and responsible person Staff are falsifying residents records Staff did not seek timely medical attention for resident
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Administrator Mike O'Neil at 10:50 AM and explained the purpose of the visit. LPA Rosales conducted the initial Complaint visit on 04/30/2021 at 1:56PM, virtually toured the facility, conducted telephonic interview with Administrator at 2:23pm and requested copies of pertinent documents, interviewed staff at 10:39 AM, 12:07 PM. LPA Rosales conducted a subsequent complaint visit on 06/15/2021 at 10:04 AM, toured facility and interviewed staff at 11:45 AM, 12:09 PM, 1:01 PM, 2:06 PM and interviewed resident at 1:21 PM. During the investigation LPA Rosales conducted staff interviews on 05/24/2021 at 11:48 AM, 12:05 PM, 12:14 PM, 06/04/2021 at 2:21 PM, 06/07/2021 at 4:14 pm, and 06/18/2021 9:22 AM. LPA Rosales interviewed resident on 10/05/2021 at 3:08 PM and Witness on 05/18/2021 at 1:25 PM. LPA Ascencio interviewed staff on 05/05/CDSS inspection report, April 17, 2023 · control 29-AS-20210422132534
Complaint investigationAllegation reviewed · Substantiated
Allegation the state reviewedFacility staff did not provide timely medical attention for a resident in care Staff are not adequately meeting a resident's needs Resident has significant weight loss
State's findingSubstantiatedThe state investigated and found this allegation more likely than not true.
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Administrator Mike O’Neil at 10:50 AM and explained the purpose of the visit. LPA Rosales conducted the initial complaint visit on 05/24/2021 at 10:50 AM, toured facility, reviewed resident’s records, and interviewed staff at 11:48 AM, 12:05 PM, and 12:14 PM. LPA’s Rosales and Guzman-Chavez and conducted a subsequent complaint to the facility on 06/15/2021 at 10:04 AM, toured facility, interviewed resident at 1:21 PM, interviewed staff at 11:45 AM, 12:09 PM, 1:01 PM, and 2:06 PM. LPA Rosales interviewed witness on 05/18/2021 at 1:25 PM. LPA Rosales interviewed staff on 06/18/2021 at 9:22 AM. SubstantiatedCDSS inspection report, April 17, 2023 · control 29-AS-20210512093307

Transcribed from CDSS complaint-investigation reports · record checked August 2, 2026.

What the state has logged

California has logged 50 state visits for this home as of August 2, 2026. These are the home's own counts, straight from that record — shown beside the statewide median for larger communities (16+ beds), computed across all 1,244 licensed homes of that size, because larger and longer-licensed homes naturally accumulate more visits and reports. They are facts, not a grade — a citation may be minor and since corrected, and an “unsubstantiated” complaint is not a finding of wrongdoing.

Type A citations
17
typical for this size: 1
Type B citations
19
typical for this size: 1
Substantiated complaints
46
typical for this size: 2
Total complaints
22
typical for this size: 7
State visits on file
50
typical for this size: 19
See the full inspection record on the state's site →
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