Health inspection·July 15, 2025

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure four employees working as Certified Nursing Assistants (CNAs 1, 2, 3, and 4) had valid and up-to-date CNA certifications. 2. Ensure two employee personnel files (CNAs 1and 3) were complete and up to date.These failures resulted in unlicensed CNAs providing direct care to residents without proper certification and placed residents' safety at risk.1. During an interview on [DATE] at 10:05 a.m. with the Director of Staff Development (DSD), DSD stated the CNA is responsible for maintaining up to date certification and I double check with the files. DSD further stated we had to check three or four months ago and knew the CNAs who were about to expire and reminded them to get it done and that they can't be on the schedule, it's paper tracking and we keep a schedule of who is due. We will let them know when it will expire and prompt them again and when they get the certification, they will bring it in. We only go online to verify if it's expiring or if they don't have the certification handy with them, we will check it. All new CNAs certifications are checked upon hire. During a concurrent interview and record review on [DATE] at 12:40 p.m. with the Director of Nursing (DON), CNA 1's personnel file was reviewed and indicated, Application for employment, dated [DATE]. DON verbalized was unable to locate verification of CNA 1's CNA certification from the California Department of Public Health (CDPH) Licensing and Certification (L&C) website in CNA 1's personnel file.During a concurrent interview and record review on [DATE] at 1:58 p.m. with the DSD, CNA 1's personnel file was reviewed. DSD was unable to locate CNA 1's CNA certification and stated, We tried to look online and it's not showing. It's not in the file from when (CNA 1) was hired .We usually print it out, but we didn't for this one.At the moment there's no proof CNA 1 has a CNA license.We should have printed it out, and I'm not sure if we just verified it and didn't put it in the file.During a review of CNA 1's Human Resources Workday (HRWD), print outs (work hours clocked for payroll), the HRWD indicated, Worker (CNA 1). Job Profile CNA-H and dates worked indicated, CNA 1 worked the following days, 14 days in [DATE] days in [DATE] days in May, 19 days in [DATE], and 7 days in [DATE], for a total of 67 days worked without a CNA certification.During a review of CNA 1's Application for employment, dated [DATE], the Application for employment, indicated, Job Applied to CNA/FT (full time), Question - If applying for a position that requires a medical license or certification, please enter the license number and state. If not, enter NA, Answer is blank, and Offer details - Hire Date [DATE]. Job Profile CNA-H. Business Title CNA. Scheduled Weekly Hours 40.During a concurrent interview and record review on [DATE] at 3:03 p.m. with the DON and Administrator (ADM), the facility's policies and procedures (P&P) titled, Compliance Risks - Resident Quality of Care and Quality of Life, dated [DATE], and Staffing, Sufficient and Competent Nursing, dated [DATE], were reviewed. In addition, Job Description: Certified Nursing Assistant, dated 02/2024 and (facility) CNA schedule dated [DATE] through [DATE] were also reviewed. P&P titled, Compliance Risks - Resident Quality of Page 1 of 3 055861 055861 07/15/2025 Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Care and Quality of Life, indicated, .Sufficient staffing (1) Staffing is provided in sufficient numbers and with staff who have appropriate clinical training, licensure, and/or expertise to meet the needs of residents.Staff screening (1) Background screening and investigations are conducted prior to employment or engagement to ensure that staff, contractors, and/or volunteers meet at least the following criteria: (a) current licensure (if applicable) is in good standing in the state of practice; (b) education, certifications, and training have been verified. P&P titled, Staffing, Sufficient and Competent Nursing, indicated, .Competent staff (2) All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. The Job Description: Certified Nursing Assistant, indicated, .Must be a licensed Certified Nursing Assistant in accordance with laws of the state. DON and ADM confirmed both P&Ps and CNA Job Description were not followed. DON and ADM confirmed CNA 1 was listed on (facility) CNA schedule, and worked multiple days each month from [DATE] through [DATE], CNA 1's CNA certification was not in CNA 1's personnel file, and CNA 1 worked these shifts without verification of CNA certification.During a concurrent interview and record review on [DATE] at 2:55 p.m. with the ADM, CNA 2's personnel file and CNA schedules, dated October and [DATE] were reviewed. CNA 2's personnel file indicated, CNA 2's certification date of [DATE], expiration date [DATE], and a second certification, effective date [DATE], expiration date [DATE], verified by the CDPH L&C website. CNA 2 did not have a valid CNA certification from [DATE] through [DATE]. Review of the CNA schedules indicated, CNA 2 worked 5 days in [DATE] from [DATE] to [DATE] and 12 days in [DATE] from [DATE] through [DATE]. ADM was unable to locate CNA 2's valid CNA certification from [DATE] through [DATE]. The ADM confirmed CNA 2 worked the dates as noted above without a valid CNA certificate.During a concurrent interview and record review on [DATE] at 3 p.m. with the DON, CNA 2's personnel file was reviewed. DON verbalized CNAs would not be here at that time while CNA certification is processing and further stated, We are supposed to check each staff to make sure their CNA certification is current and valid and make sure that everything is current. DON confirmed CNA 2's CNA certification was expired from [DATE] through [DATE], and CNA 2 was not certified while working as a CNA during that timeframe.During an interview on [DATE] at 3:51 p.m. with the DSD, DSD stated, We didn't have a process in place to ensure (CNA 1) renewed their CNA certification. We didn't have the right process.During a concurrent interview and record review on [DATE] at 4:34 p.m. with the DSD, CNA 3's personnel file undated, and Nursing Staff Daily Assignment & Sign-In Sheet, dated 2/16 and [DATE], and HRWD print outs were reviewed. CNA 3's personnel file indicated, Certified Nursing Assistant Certification.Effective Date [DATE]. Expiration Date [DATE], and Effective Date [DATE]. Expiration Date [DATE]. Verified by the CDPH L&C website. Nursing Staff Daily Assignment & Sign-In Sheet, dated [DATE] and [DATE] indicated, CNA 3's signature next to CNA 3's name. HRWD print outs indicated, CNA 3 worked 2/16 and [DATE]. DSD confirmed CNA 3 worked on [DATE] and [DATE] without an active CNA certification.During a concurrent telephone interview and record review on [DATE] at 3:25 p.m. with the ADM, CNA 4's personnel file and CNA 4's HRWD print outs were reviewed. CNA 4's personnel file indicated, Certified Nursing Assistant Certification Effective Date [DATE]. Expiration Date [DATE], and Effective Date [DATE]. Expiration Date [DATE], verified by CDPH L&C website. HRWD print outs indicated, CNA 4 worked four days in July from [DATE], through [DATE] and ten days in August from [DATE] through [DATE]. ADM confirmed accuracy of all records reviewed and stated, According to these documents (CNA 4) was not actively certified while working these dates.During a review of the facility's Policy and Procedure (P&P) titled, Credentialing of Nursing Service Personnel, dated [DATE], the P&P indicated, Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the 055861 Page 2 of 3 055861 07/15/2025 Ojai Health & Rehabilitation 601 North Montgomery Street Ojai, CA 93023

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scope of the individual's license or certification must present verification of such license or certification prior to or upon employment. 1) Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the director of nursing services prior to or upon employment. 2) Nursing personnel requiring a license/certification are not permitted to perform direct resident care until all licensing/background checks have been completed. 3)a) contact the appropriate state licensing board(s) to obtain a letter of verification/computer printout of such license/certification.4) A copy of all documents obtained during the verification and background check are filed in the employee's personnel file.6) Should the investigation reveal the applicant does not hold a valid license or certification, appropriate state licensing boards and authorities will be notified of the applicant's attempt to practice without a license/certification .9) Inquiries concerning credentialing should be referred to the administrator or the director of nursing services.2. During a concurrent interview and record review on [DATE] at 3:25 p.m. with the DON and Administrator (ADM), CNA 1's personnel file was reviewed. The DON and ADM verbalized they were unable to locate CNA 1's signed job description and CNA 1's personnel file was incomplete.During a concurrent interview and record review on [DATE] at 2:40 p.m. with the DSD, CNA 3's personnel file was reviewed. DSD verbalized CNA 3's start date was [DATE]. When asked if CNA 3's personnel file contained verification of CNA 3's CNA certification back in 2023, DSD stated we don't have the old one, just the most recent, we should get a printed copy and put it in their file, but this file was created before me. DSD further stated we can't search online for previous CNA certifications, and it's missing from when CNA 3 was hired.During a review of the facility's Policy and Procedure (P&P) titled, Personnel Records, dated [DATE], P&P indicated, 1. Federal and state regulations require that our facility maintain an individual personnel record for each employee. However, it shall be the employee's responsibility to provide the HR director with the required data. This responsibility also entails notifying, in writing, the HR director of any change in the required data.3) Personnel records contain, as each may apply, the following data.(c) Job description(s).(l) Copy of current licenses (as applicable).15) Personnel records shall be retained for a period of not less than five (5) years unless otherwise required by federal or state laws.During a review of the facility's Personnel File - Required Checklist - Physical and Workday, dated [DATE], Personnel File - Required Checklist - Physical and Workday, indicated, Employment/Onboarding Items.Education verification (licensure uploaded to in Workday under Career, for monthly monitoring).License required for position (Upload copy into Workday).Job description (it needs to be employee acknowledged; it is assigned in Workday). 055861 Page 3 of 3