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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601952
Report Date: 03/20/2024
Date Signed: 03/20/2024 04:07:58 PM


Document Has Been Signed on 03/20/2024 04:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:BROOKDALE OCEANSIDEFACILITY NUMBER:
374601952
ADMINISTRATOR:CHRISTOPHER BURKFACILITY TYPE:
740
ADDRESS:3524 LAKE BLVDTELEPHONE:
(760) 945-1811
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:186CENSUS: 88DATE:
03/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Candi LairdTIME COMPLETED:
04:15 PM
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LPA Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself, and discussed the purpose of the visit with Executive Director Candi Laird.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/13/2024). According to the LIC624: during the morning of 03/12/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA collected copies of and reviewed pertinent care records, training records, and physician correspondence. LPA also interviewed relevant staff.

Staff interviews aligned to show: On the morning of 03/12/2024, S1 was a newer Medication Technician and recently underwent medication pass training with a nurse manager. At breakfast time, Staff #1 approached R1 and asked R1 to verify his identity, R1 agreed to the wrong identity. R1 then ingested medications which were not prescribed to them. Staff quickly recognized the error and timely notified R1’s primary care physician (PCP).

Staff measured R1’s blood pressure multiple times, finding it was consistently within a safe range. Staff continued to closely observe R1 for 72 hours and R1 had no adverse reactions.

[Continued on 809-C]

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BROOKDALE OCEANSIDE
FACILITY NUMBER: 374601952
VISIT DATE: 03/20/2024
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[Continued from 809]


Personnel records showed that Licensee provided one-on-one remedial medication pass training to S1 following the incident.

No citations were issued at the time of visit however one (1) Technical Violation (TV) was issued.. An exit interview was conducted with Executive Director Candi Laird, to whom a copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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