Ojai Meadows

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cotez conducted an unannounced Case Management – Incident inspection pertaining to self-reported Special Incident Reports (SIRs) received on 05/26/2026 and 08/01/2026. The LPA met with Executive Director Christopher Tarp and informed them the reason for the visit. The self-reported SIRs pertains to medication errors that occurred on 05/24/2026 and 08/01/2026. It was reported that on 05/24/26 a resident (R1) received the wrong medications (melatonin, eliquis, and cephalexin that were intended for another resident. Resident was transported for to the ER for further evaluation and had no new orders or changes in condition. It was reported that on 08/01/26 at 9:00 AM, a resident (R2) received Bupropion HCL XL 150MG medication that was intended for 4:00 PM. During today's visit also in conjunction with complaint control number 29-AS-20260812102934 the LPA observed a fax communication dated 08/12/2026, from the facility to Resident's 3 (R3) primary physician to notify them that R3 was given Seroquel 25mg tablets intead of 12.5 (1/2) tablet. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued to the ED.the state’s words, verbatim · CDSS document, Aug 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 21, 2026

87465(a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above for three residents (R1, R2, R3), that had medication errors which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Executive Director and Resident Care Director revealed that MT's that made the medication errors have been retrained, and will submit of proof of training, and if no training has been provided will retrain and/OR submit proof of retraining and or demotion of MT role per the RCD.

Allegation investigated: Facility staff did not refund resident's authorized person upon the death of the resident as required

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct an initial complaint inspection for the allegation listed above. The LPA met with Executive Director Andrea Davis and entrance interview conducted. During today's visit, LPA interviewed the Executive Director, reviewed and gathered copies of pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Substantiated Regarding the allegation, “Facility staff did not refund resident's authorized person upon the death of the resident as required”; It was alleged that the facility staff did not provide a refund to Resident #1’s (R1’s) Authorized Person (AP) after R1 passed away within the required 15 days per the admission agreement. It was further alleged that R1’s AP did not receive the refund until 12/29/2025. Interview with the Executive Director (ED) revealed that R1 expired on 11/29/2025, and on 11/30/2025 all their belongings had been removed, and their account had been closed. On 12/1/2025, the ED notified R1’s AP that R1 had been removed from any future billing, and their account was no longer set for any additional payments via text message. If a payment happened to process earlier that morning before everything was updated for the AP to inform them so they could begin the refund process right away. On 12/2/2025, the ED was notified by the AP that December’s payment was withdrawn and to please start the refund. R1's Admission Agreement states that "discharge/death - any refund of the monthly fee that is owed to the Resident/Representative will be returned within fifteen (15) days." As the resident passed away on 11/29/2025 and all belongings were removed on 11/30/2025, a refund should have been issued by 12/15/2025. The ED stated that she was informed that a check had been generated and mailed out but did not know when. The ED provided the LPA with a detailed ledger for R1 where it revealed that a check for R1’s AP was “effective” 12/16/2025, however was unable to provide documentation verifying the date the check was mailed or issued to the AP. Additionally, the ED stated that they had received confirmation that the check was received on 12/29/2025, and provided the LPA an image of the check with the amount of $8455.00 dated 12/16/2025 and that it had been cleared from the bank today 12/30/2025. Therefore, based on interview and record review, the allegation that " Facility staff did not refund resident's authorized person upon the death of the resident as required " is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9009-D): Exit interview conducted, today’s report and appeal rights were reviewed and emailed to the Executive Director.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 29-AS-20251226092900

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Dec 31, 2025

§1569.652 Termination of admission agreement upon death of resident... and refunds (c) A refund of any fees paid in advance...shall be issued...to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by Based on interview and record review, the facility did not comply with the above cited section, as R1 passed away on 11/29/25, belongings were removed on 11/30/25 and check issued was dated 12/16/25, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: On 12/30/25, family of R1 confirmed they had received the refund from the facility and the ED also agreed to review section cited and submit a statement of understanding and plan to ensure future compliance and send to LPA by 12/31/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit. LPA Cortez met with Executive Director Andrea Davis at approximately 3:30 pm and explained the purpose of the visit. On 12/30/2025, Community Care Licensing Division (CCLD) received a self-reported LIC624 Unusual/Incident Report pertaining to Resident 1 (R1) who was reported to have broken their 6th and 7th rib. During today’s visit, LPA Cortez reviewed and obtained documents pertaining to the investigation and conducted in-person interviews with the ED, Care Director and R1. Staff interviews revealed that R1 is diagnosed with Dementia however, was not a fall risk prior to this incident, does not use a walker, and is able to walk on their own and independent. R1 was taken to the hospital and the hospital attributed the broken ribs to a possible fall, however no fall was reported by R1 or staff. To prevent future falls R1 is now being checked on hourly, is now considered a fall risk, and will be getting physical therapy with home health. Interview with R1 revealed that they were told they have two broken ribs and have a little bit of pain but do not remember any fall, staff treat them wonderful, they are able to walk on their own, do not require much care and has no concerns. Documents reviewed did not indicate R1 as a fall risk, and per their LIC602 dated 03/31/25, R1 was not deemed as disoriented, lack of hazard awareness, and was not deemed as unsafe wondering. During the visit the LPA did not observe any immediate health or safety concerns. If further investigation is warranted the LPA will return at a later date.No deficiencies noted during today’s visit. Exit interview conducted. Copy of report was issued.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Prelicensing

At 09:15 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant representative, Robert Coe. This is a a change of ownership application (CHOW). Facility has capacity for a total of fifty-seven (57) non-ambulatory and fifteen (15) bedridden residents. Fire Clearance was approved on 07/11/25. A dementia program was included in the plan of operation. Applicant representative stated a Hospice Waiver for fifteen (15) has been requested. Component III was completed during the inspection with the applicant. The LPA toured the physical plant areas inside and outside with the administrator. There are four (4) resident buildings in total. Two (2) Assisted Living (Maricopa and Sespe) and two (2) Memory Care (Topa Topa and Matilija). Memory care is set up with delayed egress. The following was noted: KITCHEN: Each building has their own kitchen and dining area. The LPA inspected the kitchen/food service area at all four buildings. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Each kitchen/food service area has a locked knives and sharps drawer and a locked cabinet where the cleaning supplies are stored. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature that ranged from 72*-75* degrees throughout the four buildings. Smoke detector(s) and carbon monoxide detectors tested were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 07/22/2025. The LPA observed required postings throughout the common spaces. The facility has a pool fully fenced with 2 locked gates for entry. Report continued on LIC 809-C. Memory Care courtyard does have a fountain. Administrator stated residents are supervised when in proximity to the water feature. BEDROOMS: There are a total of sixty-four (64) resident bedrooms with sixteen resident rooms in each building. The LPA observed ten random resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Lighting in the rooms was adequate. Signal system was tested and operable. Buildings Topa and Matilija are set up with delayed egress for memory care. RESTROOMS: There are sixty-nine (69) resident bathrooms. Resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in eight (8) randomly selected resident bathrooms from all buildings, which ranged between 107.4 degrees Fahrenheit to 125.6 degrees Fahrenheit. The LPA observed Resident bathrooms in resident rooms 301, 308 and 313 with the following hot water temperatures: 122.2 F, 125.6 F, and 120.6 F, all above the required water temperature. MEDICATION: Each building has their own locked medication room. ADMINISTRATOR'S OFFICE: Resident and staff records are be kept in a locked cabinet in the Administrators office and Business office. The following items are needed prior to issuance of license. 1. A 5 day water temperature log indicating water temperature between 105 - 120 degrees Fahrenheit. 2. Fire clearance clarification regarding locked gates in Memory Care courtyard. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted with facility the Administrator. A copy of report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 72 Census (if any clients in care): 72 COMP II Participants: Robert Coe; Steven Barklis Interview Method: Telephone interview On 08/28/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 28, 2025