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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603237
Report Date: 08/02/2023
Date Signed: 08/02/2023 03:02:50 PM


Document Has Been Signed on 08/02/2023 03:02 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:ROXIES ELDERLY HOMES IIFACILITY NUMBER:
374603237
ADMINISTRATOR:TERESITA ROXASFACILITY TYPE:
740
ADDRESS:4560 VINYARD STREETTELEPHONE:
(442) 266-2939
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 5DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee Teresita "Roxie" RoxasTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted a complaint investigation visit where an unrelated deficiency was discovered. LPA was greeted by, identified herself to, and explained the purpose of the visit to Caregiver Clarinda Griffith. Licensee Teresita "Roxie" Roxas arrived during the visit.

During today's visit, LPA conducted a tour of the facility, reviewed and obtained copies of facility records, and interviewed staff. Review of Resident 1's (R1) physician's report revealed that resident is bedridden, unable to reposition independently and is receiving hospice services. Interviews with staff and hospice staff confirmed the bedridden determination. Review of the facility's license revealed that the facility is only licensed for 1 bedridden resident to be housed in a room with a direct exit to the outside. Per California Code of Regulations Title 22, the following deficiency is cited on the attached LIC809-D page. A civil penalty in the amount of $500 has been assessed during the visit.

An exit interview was conducted with Licensee '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: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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Document Has Been Signed on 08/02/2023 03:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 II
FACILITY NUMBER: 374603237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance (a) All facilities... Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons...
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Licensee stated they will submit an LIC200 application for increased bedridden clearance and updated facility sketch to Department by POC due date.
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This requirements has not been met as evidenced by: Based on interviews and record review, the facility does not have a fire clearance for 2 bedridden residents. This poses an immediate safety risk to 1 of 5 residents in care. A civil penalty of $500 was assessed.
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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: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
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