374602252-8-4-2026-08-AS-AGOH-DW82DZ-20260721171911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602252
Report Date: 07/21/2026
Date Signed: 08/04/2026 11:18:00 AM

Document Has Been Signed on 08/04/2026 11:18 AM - 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 II		FACILITY NUMBER:	374602252
ADMINISTRATOR/ DIRECTOR:	SIERA NAVASAK		FACILITY TYPE:	740
ADDRESS:	15 SHASTA COURT		TELEPHONE:	(760) 722-8503
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 5	DATE:	07/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:35 PM
MET WITH:	Administrator Siera Navasak and Staff Vikone Veopradith and Petrada "Alice" Veopradith		TIME VISIT/ INSPECTION COMPLETED:	05:25 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	Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Staff Petrada "Alice" Veopradith. Administrator Siera Navasak arrived a few minutes later. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Additionally, the facility is approved for three (3) hospice waivers. During today’s inspection there were five (5) residents in care with one (1) currently receiving hospice services. LPA and Administrator Navasak toured the interior and exterior of the facility and inspected each room. Facility sketch was consistent with the current layout of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: private bathroom sink in a dual occupancy room was 105.3F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C]

Sabel Martinez
Arian Golbakhsh
	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 08/04/2026 11:18 AM - It Cannot Be Edited

Created By: Arian Golbakhsh On 07/21/2026 at 04:26 PM

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: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(h)(1)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reivew, the licensee did not comply with the section cited above in ensuring residents received annual/ updated assessments as needed, which poses a potential health, safety or personal rights risk to four (4) out of five (5) persons in care.
	POC Due Date: 08/21/2026
	Plan of Correction
1 2 3 4	Licensee will arrange for updated medical assessments (LIC 602) for the four (4) residents with outdated ones and submit them to LPA by POC due date.

Type B

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interview, the licensee did not comply with the section cited above in ensuring the fire extinguisher was either professionally serviced annually or purchased annually, which poses a potential health and safety risk to all persons in care.
	POC Due Date: 07/29/2026
	Plan of Correction
1 2 3 4	Licensee will submit proof of fire extinguisher having been serviced by a certified professional/agency or submit proof of a newly purchased fire extinguisher to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: OCEANSIDE REST HOME II	FACILITY NUMBER: 374602252
	VISIT DATE: 07/21/2026

NARRATIVE

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[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Navasak, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. LPA observed that the fire extinguisher was last serviced in November 2024, however it remained in fair operable condition (in the green) and a Type B deficiency was issued. First aid kits were complete and readily accessible. Nearly all required licensing postings were observed in visible areas of the facility; there was no PUB 475 posting displaying contact information for anyone wishing to report a concern or complaint about any licensed facilities. LPA issued a Technical Violation (TV) and provided guidance on where the poster may be accessed and downloaded to be added to the wall.

LPA interviewed one (1) client, and the interview did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA mostly contained required documents. LPA noted that four (4) resident medical assessments (commonly known as LIC 602) were outdated, with three (3) being dated for 2023 and one (1) was dated for 2024. Two (2) of those four (4) residents were diagnosed with Dementia or Mild Cognitive Impairment (MCI). A Type B deficiency was issued for the facility not obtaining updated medical assessments annually, as required. LPA additionally noted that three (3) out of five (5) residents did not have copies of Resident Personal Rights in their file, thought two (2) had signed copies. A Technical Violation (TV) was issued and consultation provided on the regulation. Confidential records were stored in locked areas.

Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Administrator Navasak to whom a copy of this report, the two (2) LIC 9102 (TV) forms, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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