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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603236
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:15:58 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
07/05/2023 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20230705160601
FACILITY NAME:ROXIES ELDERLY HOMES IFACILITY NUMBER:
374603236
ADMINISTRATOR:TERESITA ROXASFACILITY TYPE:
740
ADDRESS:290 HOLIDAY WAYTELEPHONE:
(442) 266-2938
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Teresita ‘Roxie’ RoxasTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee did not provide planned activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to open an investigation 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 staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not provide planned activities. Interviews and LPA observations revealed that residents watch television in the mornings after breakfast and in the afternoon after lunch. The residents will also go outside in the backyard to sit or walk around when the weather permits.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 08-AS-20230705160601
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: 07/11/2023
NARRATIVE
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Interviews with the Licensee stated that the residents have not been interested in activities and the Licensee tried activities such as bingo, art projects, drawing, writing, and throwing a ball around. The Licensee stated that she does not provide activities to the residents at this time.

The Department has investigated the above-mentioned allegation and based on interviews and LPA 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, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20230705160601
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: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
87219(a)
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87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement has not been met as evidenced by:
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Licensee stated she will speak with the residents to learn what activities they would like and plan activities. Licensee stated she will develop and implement a written monthly calendar with daily activities. The Licensee will submit the calendar to the Department by POC due date.
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Based on interviews and LPA observations, the Licensee did not ensure activities were made available to residents. This poses a potential personal rights risk to 5 of 5 residents in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
07/05/2023 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20230705160601

FACILITY NAME:ROXIES ELDERLY HOMES IFACILITY NUMBER:
374603236
ADMINISTRATOR:TERESITA ROXASFACILITY TYPE:
740
ADDRESS:290 HOLIDAY WAYTELEPHONE:
(442) 266-2938
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Teresita ‘Roxie’ RoxasTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee did not allow resident to receive phone calls
Licensee did not allow resident to keep personal possessions
Licensee did not provide reasonable accommodation in resident preferences
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to open an investigation regarding the above mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to 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 staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the Licensee did not allow resident to receive phone calls, did not allow resident to keep their personal possessions, and did not provide reasonable accommodation in resident preferences.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20230705160601
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: 07/11/2023
NARRATIVE
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Interviews revealed that some residents have personal phones and used them to contact their friends and family independently without staff assistance. Interviews revealed that the other residents were unable to use a phone independently and the Licensee used her personal phone to assist those residents to call or video chat with their families. Interviews revealed that one resident’s personal phone was broken and unable to make phone or video calls, but that resident had not asked to use the facility phone to make any calls. Interviews revealed that the Licensee would offer to call the resident’s family if they asked about them. Interviews did not reveal any instances where the Licensee did not allow residents to use the facility phone. Interviews revealed that the Licensee encouraged residents and their families to bring personal belongings, such as furniture and keepsakes, when moving in. The Licensee stated that she did not encourage families to bring valuables such as jewelry or cash and that the personal belongings could not block passage to the resident’s room. Interviews and LPA observations revealed that residents had personal items in their rooms and in their possession. Interviews did not reveal any instances of the Licensee taking personal belongings away from residents or refusing to allow residents to bring personal items into the facility. Interviews revealed that the residents were encouraged to voice any likes or dislikes to staff and would be provided with options if they did not like the prepared meal. Interviews revealed that some residents preferred to stay in bed later in the morning and staff would accommodate them by assisting residents who were already awake first. Interviews did not reveal any resident concerns or unhappiness with the care provided by the staff at the facility.

The Department has investigated the above-mentioned allegations and based on interviews and LPA observations, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Licensee Teresita ‘Roxie’ Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
07/05/2023 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20230705160601

FACILITY NAME:ROXIES ELDERLY HOMES IFACILITY NUMBER:
374603236
ADMINISTRATOR:TERESITA ROXASFACILITY TYPE:
740
ADDRESS:290 HOLIDAY WAYTELEPHONE:
(442) 266-2938
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Teresita ‘Roxie’ RoxasTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Facility did not have a working telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to open an investigation regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to 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 staff.

The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the facility did not have a working phone. During today’s visit, LPA confirmed that the facility has a working telephone and that the phone number matched the information provided to the Department.

Continued on LIC9099-C page...
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20230705160601
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: 07/11/2023
NARRATIVE
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Interviews revealed that residents’ responsible parties were provided with the facility phone number. Interviews did not reveal any concerns regarding the facility’s phone number not working.

The Department has investigated the above-mentioned allegation and based on interviews and LPA observations, it was determined that the complaint allegation is Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Licensee Teresita ‘Roxie’ Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7