236804088-1-18-2024-21-AS-CARD-CZLTBU-20240118133544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 236804088
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:35:53 PM

Document Has Been Signed on 01/18/2024 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	OCEANSIDE CARE HOME LLC		FACILITY NUMBER:	236804088
ADMINISTRATOR:	OKORO, SYLVESTER		FACILITY TYPE:	740
ADDRESS:	550 S. FRANKLIN STREET		TELEPHONE:	(614) 747-3443
CITY:	FORT BRAGG	STATE: CA	ZIP CODE:	95437
CAPACITY:	5	CENSUS: 2	DATE:	01/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Annakay Busch		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility and met with Caregiver Annakay Busch. Administrator does not live in the area and was not present at the facility. At approximately 9:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 9:45AM, LPA reviewed 2 of 2 resident records and found records contained the required documentation. Medication records are thorough and contained physician's orders for each resident. At approximately 11:00AM, LPA reviewed 2 of 2 staff records. Staff records did not contain evidence of completed CPR certification. At approximately 11:45AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills monthly. Continued on LIC 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/18/2024 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE CARE HOME LLC	FACILITY NUMBER: 236804088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 of 2 records reviewed. Staff did not have current CPR certification. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/19/2024
	Plan of Correction
1 2 3 4	Licensee to schedule staff for CPR training by POC date of 01/19/2024. Evidence of completed training to submitted to CCL by POC date of 02/16/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/18/2024 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE CARE HOME LLC	FACILITY NUMBER: 236804088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(a)

Other Provisions

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted, the licensee did not comply with the section cited above. Administrator is not present in the facility a sufficient number of hours to ensure proper facility operation. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Licensee to ensure a certified Administrator is present at the facility during normal business hours to ensure the facility is in compliance. Written plan describing Administrator hours at facility to be submitted to CCL by POC date of 2/16/2024.

Type B

Section Cited

HSC

1569.319(a)

Regulations

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Facility does not have a device for residents to use, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Licensee to ensure facility has a dedicated device for residents to use the internet. Self certification to be submitted to CCL by POC date of 2/16/2024.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE CARE HOME LLC	FACILITY NUMBER: 236804088
	VISIT DATE: 01/18/2024

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC308- Designation of Responsibility
LIC500- Personnel Report
LIC610E- Disaster Plan
Evidence of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Annakay Busch and Appeal rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC809 (FAS) - (06/04)

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