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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602252
Report Date: 05/17/2024
Date Signed: 05/17/2024 12:09:21 PM

Document Has Been Signed on 05/17/2024 12:09 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:OCEANSIDE REST HOME IIFACILITY NUMBER:
374602252
ADMINISTRATOR/
DIRECTOR:		SIERA NAVASAKFACILITY TYPE:
740
ADDRESS:15 SHASTA COURTTELEPHONE:
(760) 722-8503
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
05/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Caregiver Jay ElevadoTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Jay Elevado. LPA spoke with Administrator Siera Navasak via phone during the visit.

The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 4 of which were non-ambulatory. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Siera Navasak and their certificate is pending.

During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. The facility’s water temperature was measured at 106.9 degrees Fahrenheit in a common bathroom and 106.5 degrees Fahrenheit in a private resident bathroom. LPA observed broken tiles and exposed insulation in the private resident shower and according to staff, the shower wall has been broken for at least 1 week and staff are still using the shower to bathe residents. The facility’s internal temperature was measured at 72 degrees Fahrenheit. LPA observed cleaning chemicals stored in unlocked cabinets in the facility kitchen and a private resident bathroom. Staff relocated the cleaning chemicals to locked storage during the visit. According to Elevado, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPA observed that resident medications were pre-poured into weekly pillboxes and were not in their original container. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: OCEANSIDE REST HOME II
FACILITY NUMBER: 374602252
VISIT DATE: 05/17/2024
NARRATIVE
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Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, and documents regarding safeguarding personal property. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiencies for facility disrepair, pre-poured medications, and unlocked cleaning chemicals are being cited and noted on the attached LIC809-D pages.

An exit interview was conducted with Caregiver Jay Elevado, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/17/2024 12:09 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 05/17/2024 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME II
FACILITY NUMBER: 374602252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that cleaning chemicals were stored in unlocked cabinets in the facility kitchen and in a private resident bathroom, which poses an immediate safety risk to 6 of 6 residents in care.
POC Due Date: 06/14/2024
Plan of Correction
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LPA observed staff relocate cleaning chemicals to locked storage during the visit. Administrator will schedule staff training for proper chemical storage and submit sign in sheets to the Department by POC due date of 6/14/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/17/2024 12:09 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 05/17/2024 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME II
FACILITY NUMBER: 374602252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the shower wall in a private resident bathroom was damaged and had not been repaired or made inaccessible to residents. This poses a potential safety risk to 6 of 6 residents in care.
POC Due Date: 05/27/2024
Plan of Correction
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Administrator will inform staff to stop showering residents in the damaged bathroom and will repair the broken tiles in the shower. Administrator will submit pictures of the repaired shower wall to the Department by POC due date of 5/27/2024.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that 6 of 6 residents' medications were prepoured into weekly pillboxes which poses a potential health risk to 6 of 6 residents in care.
POC Due Date: 06/14/2024
Plan of Correction
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Administrator will schedule proper medication storage and administration training for staff and will submit sign in sheets to the Department by POC due date of 6/14/2024.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
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