Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
055861
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055861
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ojai Health & Rehabilitation
601 North Montgomery Street
Ojai, CA 93023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055861
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055861
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ojai Health & Rehabilitation
601 North Montgomery Street
Ojai, CA 93023
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0728
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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).
Event ID:
Facility ID:
055861
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F728 - Requirement for facility hiring and use of nurse aides-
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.
FAQ · About this visit
Common questions about this visit
What happened during the July 15, 2025 survey of Ojai Health & Rehabilitation?
This was a inspection survey of Ojai Health & Rehabilitation on July 15, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Ojai Health & Rehabilitation on July 15, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked l..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.