374603236-2-16-2023-08-AS-LTEZ-CPH6VG-20230228200842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603236
Report Date: 02/16/2023
Date Signed: 02/16/2023 04:07:51 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20230210112934

FACILITY NAME:	ROXIES ELDERLY HOMES I		FACILITY NUMBER:	374603236
ADMINISTRATOR:	TERESITA ROXAS		FACILITY TYPE:	740
ADDRESS:	290 HOLIDAY WAY		TELEPHONE:	(760) 722-5920
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 3	DATE:	02/16/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee Teresita "Roxie" Roxas		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Licensee restrained residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to investigate a complaint regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Licensee Teresita "Roxie" Roxas.

During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and the Licensee.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, LPA observations, and a tour of the facility. It was alleged that the Licensee restrained residents. Interviews revealed that in February 2023, 3 residents were observed to be in barricaded in their beds by chairs, a dresser, and full bed rails with no standing room on any side of the beds.
Continued on LIC9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230210112934

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROXIES ELDERLY HOMES I	FACILITY NUMBER: 374603236
	VISIT DATE: 02/16/2023

NARRATIVE

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During today's visit, LPA Ruiz observed full bed rails on 3 residents beds. Interviews and records review revealed that 2 of 3 residents are on hospice and 1 hospice resident has an order for full bed rails. Interviews revealed that the residents are placed in their beds and the bed rails are pulled into an upright position for residents between 3pm and 5pm. The Licensee stated that the bed rails remain in the upright position overnight and are lowered in the morning around 7:00am. Interviews revealed that the bed rails, chairs, and furniture are used to alert the Licensee if a resident is getting up while on the overnight shift. Interviews revealed that the full bed rails are used to prevent the residents from falling during the night.

The Department has investigated the above-mentioned allegation and based on interviews, record review, and observations, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensee Teresita "Roxie" Roxas, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230210112934

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROXIES ELDERLY HOMES I	FACILITY NUMBER: 374603236
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2023 Section Cited CCR 87608(a)(1)	1 2 3 4 5 6 7	87608 Postural Supports (a) Postural supports shall be ... used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including... preventing a resident from falling out of bed, a chair, etc.	1 2 3 4 5 6 7	Licensee removed bedrails for R3 during the LPA's visit. Licensee will attend vendor training for postural supports and submit proof of completion to the Department by POC due date of 3/16/2023.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on interviews, records review, and observations, the Licensee did not ensure bed rails were used for mobility. This poses an immedate safety risk to 2 of 3 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC9099 (FAS) - (06/04)

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