374603841-1-30-2023-08-AS-SJAB-CNM2QV-20230131163633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603841
Report Date: 01/23/2023
Date Signed: 01/30/2023 08:44:44 AM

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
11/03/2022 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20221103112339

FACILITY NAME:	OCEANSIDE ELDERLY CARE HOME 448		FACILITY NUMBER:	374603841
ADMINISTRATOR:	ALVI, MUHAMMED		FACILITY TYPE:	740
ADDRESS:	448 FOUSSAT RD		TELEPHONE:	(760) 807-8585
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	6	CENSUS: 3	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Alvi Muhammed		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility has infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA met with Licensee Alvi Muhammed, identified herself and stated the purpose of the visit.

The Department’s investigation consisted of outside source interviews, staff interviews, and a facility records review.

It was alleged facility staff is not addressing a pest infestation. Pictures were observed of the infestation. An Outside Source (OS1) interview revealed at the time the complaint was filed they observed an pest issue at the facility. Interviews with Outside Sources and a records review corroborated the information provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

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 5

Control Number 08-AS-20221103112339

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: OCEANSIDE ELDERLY CARE HOME 448	FACILITY NUMBER: 374603841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2023 Section Cited CCR 87555	1 2 3 4 5 6 7	General Food Service Requirements: All food shall be...stored...in a safe and healthful manner (b) (27) All kitchen areas shall be..clean and free...vermin and insects. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee Alvi Muhammed immediately put a contract in place with a pest control agency and provided LPA with the service contract. Deficiency has been cleared.
	8 9 10 11 12 13 14	Based on LPA observations, Licensee had an infestation at the facility. This posed a potential health risk to 2 out of 2 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
11/03/2022 and conducted by Evaluator Debbie Correia

COMPLAINT CONTROL NUMBER: 08-AS-20221103112339

FACILITY NAME:	OCEANSIDE ELDERLY CARE HOME 448		FACILITY NUMBER:	374603841
ADMINISTRATOR:	ALVI, MUHAMMED		FACILITY TYPE:	740
ADDRESS:	448 FOUSSAT RD		TELEPHONE:	(760) 807-8585
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	6	CENSUS: 3	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee Alvie Muhammed		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Licensee does not maintain facility clean and sanitary.
Licensee does not maintain the facility in good repair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA met with Licensee, Alvie Muhammed identified herself and stated the purpose of the visit.

The Department’s investigation consisted of outside source interviews and a facility tour. LPA Correia also secured photos of the facility.

It was alleged the Licensee does not maintain a clean and sanitary facility. LPA Correia conducted a facility tour and observed the facility to be sanitary and free of clutter. An interview with the Licensee revealed he has a hired cleaning service that comes to the facility. Licensee provided LPA the cleaning services information. It was also alleged the facility was not in good repair. During LPAs tour of the facility all appliances and fixtures were operable. There was no damage to the facility observed during the tour.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 08-AS-20221103112339

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: OCEANSIDE ELDERLY CARE HOME 448	FACILITY NUMBER: 374603841
	VISIT DATE: 01/23/2023

NARRATIVE

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Based on observations during the facility tour the above mentioned complaint allegations were determined to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Licensee Alvi Muhammad and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to the Licensee. Licensee's signature below confirms receipt of the reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20221103112339

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: OCEANSIDE ELDERLY CARE HOME 448	FACILITY NUMBER: 374603841
	VISIT DATE: 01/23/2023

NARRATIVE

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Based on observations and interviews, the above allegation is determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on the LIC 9099-D.

An exit interview was conducted with Licensee Alvi Muhammad and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to the Licensee. Licensee's signature below confirms receipt of the reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie Correia	TELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5