Health inspection·December 11, 2025

VENTURA DISTRICT OFFICE Ojai Health and Rehabilitation - "B" CITATION Sheila Steiner, HFEN Citation number: 05-45741-22717 Health and Safety Code Section 1418.91(a)(b). (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. 72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/20/25 at 10 a.m. an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of resident abuse. During the investigation the Department determined the facility failed to: 1. Report an allegation of abuse to the Department when an allegation of sexual abuse was reported by the resident to facility staff. Resident 1 also filed a Resident Grievance/Complaint Report (RGCR), dated 10/9/25. As a result, the abuse allegation was not investigated timely by the Department and other enforcement agencies to ensure Resident 1's and other residents' safety. The allegation indicated; Resident 1 reported that a CNA (Certified Nursing Assistant) displayed inappropriate behavior. Resident 1 stated that one CNA rubbed up against him while another CNA watched. Resident 1 was a 39-year-old male admitted to the facility on 10/13/24, with diagnoses including, but not limited to; complete paraplegia (characterized by a complete loss of motor and sensory function in both legs, caused by damage to the spinal cord), malnutrition (imbalance nutrients in the body), and muscle weakness. Review of Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition, learning, and understanding) was 15, indicating cognitively intact. The facility's policy and procedure (P&P) titled, "Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigation," dated 1/2025, indicated, "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law...'immediately' is defined as within two hours of an allegation involving abuse or results in serious bodily injury." "1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The local/state ombudsman. c. The resident's representative. d. Adult protective services (where state law provides jurisdiction in long-term care). e. Law enforcement officials. f. The resident's attending physician; and g. The facility medical director. 3."Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or During a review of Resident 1's "Progress Notes (PN)," dated 10/9/25, the "PN" indicated, Resident 1 reported that a CNA (Certified Nursing Assistant) displayed inappropriate behavior. Resident 1 stated that one CNA rubbed up against him while another CNA watched. During a review of the facility's "Resident Grievance /Complaint Report (RGCR)," dated 10/16/25, the "RGCR" indicated, Resident 1 expressed feeling uncomfortable around (name of staff 1) and (name of staff 2) due to (name of staff 2) brushing up against him while turning off the call light. During an interview on 10/23/25 at 11:01 a.m. with the Administrator (ADN), the ADN stated the abuse allegation was not reported to required agencies (California Department of Public Health [CDPH] because of the lack of supporting evidence. The facility determined that the allegation was not substantiated. The facility failed to report an allegation of abuse to the Department after Resident 1 reported that a CNA (Certified Nursing Assistant) displayed inappropriate behavior. Resident 1 stated that one CNA rubbed up against him while another CNA watched. Resident 1 also filed a RGCF. This facility failure is a violation of the Health and Safety Code (H&SC) 1418.91 (a)(b) which mandates facilities to report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.