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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603841
Report Date: 03/02/2023
Date Signed: 03/05/2023 11:29:55 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
02/01/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20230201104739
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 448FACILITY NUMBER:
374603841
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:448 FOUSSAT RDTELEPHONE:
(760) 807-8585
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 6DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Alvi MuhammedTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not document administration of medication.
Facility staff administered discontinued medication to resident.

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 Administrator Alvi Muhammed, identified herself, and stated the purpose for the visit.

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

It was alleged facility staff did not document administration of medication. An Outside Source (OS1) (See LIC 811 for confidential names) interview revealed facility staff did not consistently document the administration of medication for Resident1 (R1). A facility records review confirmed R1’s medication records was missing documentation regarding the administration of medication. Further review of outside source records corroborated the missing documentation.










Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2023
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
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
02/01/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20230201104739

FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 448FACILITY NUMBER:
374603841
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:448 FOUSSAT RDTELEPHONE:
(760) 807-8585
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 4DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Alvi MohammedTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility staff is not addressing a pest issue.
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 Administrator Alvi Mohammed identified herself and stated the purpose of the visit.

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

It was alleged the facility did not address a pest issue. An interview with an Outside Source1 (OS1) revealed there were pest/rodent droppings at the facility. During a facility tour LPA observed no evidence of pests, or pest droppings throughout the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230201104739
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: 03/02/2023
NARRATIVE
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An interview with facility staff revealed the facility has a contract in place with a pest control agency for pest/rodent prevention. A records review confirmed the facility has a contract in place to provide pest control maintenance. LPA also observed the facility has placed rodent boxes around the facility.

Based on LPA’s observations, records review, and interviews conducted with staff the above allegation was determined to be unsubstantiated. An unsubstantiated finding means although the allegation may have occurred the preponderance of the evidence standard has not been met.

An exit interview was conducted with Administrator Mohammed and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided . Signature of this form confirms receipt the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20230201104739
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: 03/02/2023
NARRATIVE
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It was also alleged facility staff continued to administer discontinued medication to R1. A facility records review revealed no documentation of discontinued medication provided by R1’s healthcare provider. R1’s records included a notation created by facility staff and signed by R1’s Responsible Party (RP) on January 29,2023 that requested R1's medication be discontinued. An interview with OS1 revealed they the facility was initially notified about the change in medication in April of 2022. Facility staff interview and a records review revealed no documentation of the RP's request to discontinue R1's medication in April of 2022.

Based on records reviews and interviews, the above allegations were determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are 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 Muhammed and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) will be provided to the Licensee. Licensee's signature demonstrated agreement to the receipt of the reports will be received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230201104739
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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87506(a)
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 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained ...in the facility or...central... location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidence by:
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Administrator Alvi Muhammad has agreed to have all staff attend a training regarding medication management by a CCL approved vendorized agency. Administrator will provide proof of completion by all staff by POC due date.
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Based in LPA's interviews and records reviews staff did not maintain complete records for Resident1. This posed a potential heath risk for 1 out of 4 residents in care.
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Type B
03/30/2023
Section Cited
CCR
87465(a)(e)(2)
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Incidental Medical Care (a) A plan for incidental medical... shall be developed...in compliance with the following: (e)...written order from a physician, on a... the residents file, and a label...physician's order and the label shall contain....(2) The exact dosage.

This requirement was not met as evidenced by:
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Administrator Alvi Muhammad has agreed to have all staff attend a training regarding record retention by a CCL approved vendorized agency regarding medication orders. Administrator will provide proof of completion by all staff by POC due date.
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A facility records review revealed Resident1 did not have all health care orders regarding medication on file.

This posed a potential heath risk for 1 out of 4 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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5