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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609954
Report Date: 09/17/2026
Date Signed: 09/17/2026 04:13:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2026 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20260305161151
FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR:DAVID SCARLETTFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:0CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:Michael WeyrickTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident was sexually abused by staff while in care
Staff did not follow infection control requirements
Staff did not transfer resident according to resident’s needs and services plan
Staff handled resident in a rough manner
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez issued final findings for this investigation via US mail and email. The facility closed effective 11/18/2025.

On 03/09/2026, from 12:10pm to 12:42pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial complaint visit telephonically with the former licensee. During the investigation, documents were reviewed including Staff 1 (S1)’s employee file, court documents, and multiple videos from a discrete video recording device Resident 1 (R1)’s responsible party placed in R1’s room. During the investigation, the Department conducted the following interviews: On 03/19/2026 at 12:18pm and 03/23/2026 at 2:12pm with Executive Director; On 03/23/2026 at 9:00am with S1; on 03/24/2026 with R1’s responsible party; on 05/14/2026 at 4:56pm with former Administrator; and on 05/14/2026 at 5:06pm with former staff. In addition, multiple contacts with requests for information were made with the Ventura County Sheriff’s Department. Report will continue on LIC9099-C, 2nd page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
VISIT DATE: 09/17/2026
NARRATIVE
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On the allegations: Resident was sexually abused by staff while in care and Staff did not follow infection control requirements. It was alleged (S1) checked R1’s incontinence brief without gloves, exposed himself, touched his buttock area with gloves, then provided incontinence care to R1 while wearing the same soiled gloves.

R1’s responsible party stated they installed a camera in R1’s bedroom without the facility’s knowledge, due to concerns about R1 not being fed properly. R1’s responsible party stated R1 was non-verbal due to dementia, and was now deceased. R1’s responsible party stated it took a long time to review all the videos from the camera, but they observed S1 pulling their pants down. Videos provided by R1’s responsible party were reviewed, and responsible party indicated they were from 2022. One video showed S1 checking R1’s brief without gloves, put gloves on, dropped their pants exposing themselves, and then scratched or touched their anus. S1 then changes R1’s brief wearing the same gloves.

When S1 was interviewed, they stated they were terminated from the facility for bad hygiene. S1 stated they worked at the facility for almost four years, and typically worked at time and alone, with a supervisor doing rounds in other buildings. S1 stated they were “itchy” and confirmed they scratched their anus in a resident’s room, which they were later told had a recording device in it. S1 did not recall the resident’s name. S1 confirmed they did not wash their hands after. S1 at first stated this only occurred on this one occasion, with one resident. S1 later stated they were wearing a glove when they scratched themselves over clothing.

S1 later admitted to pulling down their pants and being nude in the resident’s bedroom. S1 admitted pulling down their pants could be “perceived as sexual abuse.” S1 admitted during the overnight shift in resident rooms, they exposed themselves, watched pornography on their cell phone, and masturbated. S1 stated they masturbated in multiple residents’ rooms on several occasions, in the presence of female and male residents with dementia, and believed all the residents were asleep. S1 admitted they did not wash their hands immediately after. S1 denied inappropriately touching residents at any time.

Former Administrator Amber Winterstein confirmed S1 was terminated from the facility, after the licensee provided a summary of the video of S1 wiping their buttocks, and then providing care to the resident. Former Administrator stated S1 admitted they had not followed proper hygiene protocols but made no other disclosures, and former Administrator did not suspect any abuse.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
VISIT DATE: 09/17/2026
NARRATIVE
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 Facility records show S1 had completed multiple training about residents’ rights, reporting abuse, and infection control. Based on the information obtained, the allegations are deemed Substantiated at this time.

On the allegations: Staff did not transfer resident according to resident’s needs and services plan and Staff handled resident in a rough manner. It was alleged R1 required two-person transfers using a hoyer lift, but multiple videos show the transfers being improperly performed and/or in a rough manner. Limited documentation was available due to the facility’s closure and the incidents investigated occurred during 2022. Documentation confirmed R1 needed staff assistance with all transfers. Documentation confirmed a hoyer lift was ordered for R1 on 04/15/2021 through their hospice care. The Department could not find any documentation to show the facility updated R1’s plan of care following the acquisition of the hoyer lift. Additionally, R1’s care plan was not updated following falls documented in medical records on 06/23/2021 and 07/03/2021. The Department reviewed the videos. One video shows two female caregivers transferring R1 from their wheelchair to their bed, with unlocked wheelchair wheels. The video shows the wheelchair move with the resident, and the staff appear to transfer R1 onto the bed with force. Another video shows one female caregiver transferring R1 from the bed to wheelchair by themselves, and forcibly places R1 into their wheelchair. R1 appears to wince in pain. Another video shows one female caregiver forcibly transferring R1 from their wheelchair to the bed, without the wheelchair brakes on. R1’s head can be seen rubbing against the wall during the transfer. One video shows one female caregiver struggling to transfer R1 from their wheelchair to bed, although the wheelchair brakes were locked. After several attempts to lift R1 from their wheelchair, the staff forcibly lifts R1, who appears to wince in pain. The staff transfers R1 to the bed, with R1’s body was dangling off the edge of the bed. The staff attempts to kick the wheelchair away so there is more room to reposition R1, and finally lifts R1’s legs into the bed. Based on the information obtained, the allegations are deemed Substantiated at this time.

Report will continue on LIC9099-C,3rd page.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
VISIT DATE: 09/17/2026
NARRATIVE
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On the allegation: Staff did not follow reporting requirements. It was alleged one improper transfer with the hoyer lift resulted in a fall that was not reported to Licensing. During the investigation, the facility file was reviewed and it was determined the facility did not submit an incident report for a fall for R1. Medical records were reviewed indicating R1 went to the Emergency Room (ER) on 06/23/2021 after a fall. Records show R1 also went to the ER on 07/03/2021 for hip pain after a fall; no fractures were noted and instead the resident was found to have a urinary tract infection. No incident report was submitted for the falls and ER visits. During the investigation, the facility file was reviewed and it was determined the facility did not submit an incident report or SOC341 for S1 exposing themselves in front of R1. The licensee was aware the incident occurred, since they informed the former Administrator about the incident. The former Administrator was also aware the incident occurred, since they terminated S1 over it. Based on the information obtained, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).
A copy of this report and appeal rights issued via mail and email.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2026
Section Cited
CCR
87468.1(a)(3)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Facility is closed, effective 11/18/2025, and licensee does not have another facility at this time.
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Based on interviews and record review, the licensee did not comply with the section cited above when S1 masturbated in the presence of residents, which posed an immediate health, safety and personal rights risk to residents in care.
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Type A
09/17/2026
Section Cited
CCR
87468.2(a)(4)
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(a)…residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by:
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Facility is closed, effective 11/18/2025, and licensee does not have another facility at this time.
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Based on video evidence, the licensee did not comply with the section cited above when staff roughly handled R1 during transfers, which posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87211
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including…Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents…This requirement is not met as evidenced by:
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Facility is closed, effective 11/18/2025, and licensee does not have another facility at this time.
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Based on video evidence, the licensee did not comply with the section cited above when they did not report S1’s inappropriate behavior or R1’s falls, which posed a potential health and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2026 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20260305161151

FACILITY NAME:ARTESIAN OF OJAI, THEFACILITY NUMBER:
567609954
ADMINISTRATOR:DAVID SCARLETTFACILITY TYPE:
740
ADDRESS:203 E EL ROBLAR DRIVETELEPHONE:
(805) 798-9305
CITY:OJAISTATE:CAZIP CODE:
93023
CAPACITY:0CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not treat resident with dignity or respect
Staff did not ensure that resident received adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez issued final findings for this investigation via US mail and email. The facility closed effective 11/18/2025.

On 03/09/2026, from 12:10pm to 12:42pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial complaint visit telephonically with the former licensee. During the investigation, documents were reviewed including Staff 1 (S1)’s employee file, court documents, and multiple videos from a discrete video recording device Resident 1 (R1)’s responsible party placed in R1’s room. During the investigation, the Department conducted the following interviews: On 03/19/2026 at 12:18pm and 03/23/2026 at 2:12pm with Executive Director; On 03/23/2026 at 9:00am with S1; on 03/24/2026 with R1’s responsible party; on 05/14/2026 at 4:56pm with former Administrator; and on 05/14/2026 at 5:06pm with former staff. In addition, multiple contacts with requests for information were made with the Ventura County Sheriff’s Department. Report will continue on LIC9099-C, 2nd page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20260305161151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARTESIAN OF OJAI, THE
FACILITY NUMBER: 567609954
VISIT DATE: 09/17/2026
NARRATIVE
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On the allegation: Staff did not treat resident with dignity or respect. One video reviewed shows two female caregivers preparing to change R1’s brief. As one of the female caregivers uncovers R1's blankets she waves her hand near the resident's brief, a gesture consistent with signaling a heavy odor to her coworker. Additionally, both caregivers are wearing protective face masks, not allowing it possible to accurately verify facial expressions, talking or laughing. Furthermore, the video has no audio component. Based on the information obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred therefore the allegation is Unsubstantiated at this time.

On the allegation: Staff did not ensure that resident received adequate food service. It was alleged that staff fed R1 so quickly that they began choking. One video shows one female caregiver feeding R1 something hot from a mug, as the staff was blowing on the spoon to cool it. The staff puts the spoon to R1’s mouth, and forcibly adjusts R1’s head to be more upright. The staff provided spoonfuls in succession before R1 is done chewing. After approximately five minutes of feeding, R1 appears to shake and struggle, and the caregiver appears concerned. R1 lays their head further down and the caregiver does not move R1 but runs out of the room to get assistance. Three additional caregivers enter R1’s room and elevate R1 on the bed. R1 is placed on their side. Several minutes later, emergency responders enters the room to provide R1 assistance, and R1 is taken away on a gurney. The videos do not appear to show staff or first responders performing a Heimlich maneuver on R1, and R1 does not appear to be choking after the initial shaking movements. There was no incident report submitted regarding the incident. Based on the information obtained, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred therefore the allegation is Unsubstantiated at this time.

A copy of this report and appeal rights issued via mail and email.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8