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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603841
Report Date: 02/28/2024
Date Signed: 02/29/2024 06:35:19 PM


Document Has Been Signed on 02/29/2024 06:35 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: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: 5DATE:
02/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Caregiver Christopher DiazTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Correia conducted an unannounced Case Management visit to cite deficiencies. LPA was greeted by Caregiver Diaz identified herself and discussed the purpose of the visit with Caregiver Diaz.Today’s visit was in response to information obtained while conducting a complaint investigation.

The Department received a complaint on February 22, 2022, alleging neglect by staff neglect resulting in a serious injury. Over the course of the investigation interviews and records reviews revealed Resident 1 (R1) sustained a head injury as a result from a fall. Facility staff notified the Licensee who directed staff to notify R1's Responsible Party (RP). Facility staff interviews and outside source interviews and records reviews revealed 911 was not initiated for nearly an hour after R1 sustained a head injury. Per Title 22 mandate, 911 shall be initiated immediately after residents in care sustain a head injury.

An exit interview was conducted with Caregiver Christopher Diaz to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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 02/29/2024 06:35 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: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
CCR
87465

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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...

This requirement was not met as evidenced by:

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An all staff will attend CCL approved training regarding incidents that occur that require immediate medical intervention including activating a 911 call.

Proof of POC will be provided by POC due date.
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Based on staff and outside source interviews and records reviews revealed the Licensee did not immediately telephone 911 after Resident 1 (R1) sustained an injury deemed an imminent threat to their health.

This posed an immediate safety risk to [R1] 1 out of 6 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: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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