374603237-6-24-2024-08-AS-JLOT-D6PUHU-20240629153631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603237
Report Date: 06/24/2024
Date Signed: 06/24/2024 10:36:03 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
08/13/2021 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20210813081420

FACILITY NAME:	ROXIES ELDERLY HOMES II		FACILITY NUMBER:	374603237
ADMINISTRATOR:	TERESITA ROXAS		FACILITY TYPE:	740
ADDRESS:	4560 VINYARD STREET		TELEPHONE:	(760) 637-2789
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	06/24/2024
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Licensee Teresita "Roxie" Roxas		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility staff locked resident in their room

INVESTIGATION FINDINGS:

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

The Department’s investigation consisted of interviews with staff and outside sources and a tour of the facility. It was alleged that facility staff locked residents in their room, specifically Resident 1 (R1). During an on-site visit to the facility on 8/17/2021, the Department observed a doorknob with a locking mechanism that was installed on a resident’s bedroom door that allowed the door to be locked from the outside of the room. During the onsite visit on 8/17/2021, the Department visually confirmed that the Licensee removed the doorknob with the locking mechanism during the visit. During interviews, the Licensee denied installing the doorknob or locking any residents in their rooms. Staff denied locking residents in their rooms during interviews, however, outside sources provided conflicting information.
Continued on LIC9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

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-20210813081420

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROXIES ELDERLY HOMES II	FACILITY NUMBER: 374603237
	VISIT DATE: 06/24/2024

NARRATIVE

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Multiple outside sources alleged that facility staff had made statements indicating that R1 was locked in their room when R1 was experiencing behaviors, including wandering and exit seeking. Interviews and interactions with facility staff revealed that facility staff, including the Licensee, were not truthful with Department representatives during interviews. The Department was unable to interview R1 due to R1 no longer residing at the facility.

The Department has investigated the above-mentioned allegation and based on interviews 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 "Roxie" Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210813081420

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROXIES ELDERLY HOMES II	FACILITY NUMBER: 374603237
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/08/2024 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) residents… shall have all of the following personal rights (6) … to not be locked in any room, building, or on facility premises by day or night… This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee removed locking door knob during visit on 8/17/2021. Licensee and staff will attend an outside vendor training on personal rights and will submit a sign in sheet to the Department by POC due date of 7/8/2024.
	8 9 10 11 12 13 14	Based on interviews and observations, the licensee did not comply with the above regulation in that residents were locked in their room, which poses a potential personal rights risk to 6 of 6 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: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024

LIC9099 (FAS) - (06/04)

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