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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603841
Report Date: 02/28/2024
Date Signed: 03/12/2024 05:41:48 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
02/24/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20230224152348
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: 3DATE:
02/28/2024
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Caregiver Christopher DiazTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Staff did not allow resident to have visitors during reasonable hours.
Staff did not ensure records of centrally stored medication were complete.
Staff did not ensure medication was available for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Correia conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Caregiver Diaz.

The Department’s investigation included staff, resident, and outside source interviews. The investigation also included facility and outside source records reviews, and a facility tour.

It was alleged facility staff did not ensure medication was available for a resident in care. Interviews and record reviews revealed on February 22, 2023, Resident 1 (R1) sustained a fall at the facility that resulted in a head injury. An interview conducted with an Outside Source 1 (OS1) revealed they saw R1 approximately one hour after the fall and observed a large lump on the left side of R1’s forehead. Subsequently, OS1 called 911, and asked facility staff to ensure R1’s medication records were provided to medical personnel when they arrived to transport R1 to the hospital. Additionally, OS1 revealed they received a phone call at 9:17 p.m. from staff at the hospital where R1 was transported, requesting R1’s medication information and confirmed the facility staff did not provide R1’s complete medication list. At that time OS1 was also informed R1 could return to the facility the next day. A review of facility and outside source records corroborated the allegation.

This is an amended version of the report dated 02/28/2024.
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: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
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 6
Control Number 08-AS-20230224152348
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: 02/28/2024
NARRATIVE
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It was also alleged that staff did not ensure R1’s records of centrally stored medication was complete. R1 returned to the facility upon discharge from the hospital the following day, February 23, 2023, at approximately 8:00 a.m., from being admitted for the treatment of a head injury after sustaining a fall at the facility. An interview conducted with OS1 revealed they arrived at the facility on February 23, 2023, at approximately 9:00 a.m., one hour after R1’s return, and requested Staff 1 (S1) to see R1’s Medical Administration Record (MAR), which is used to document dates and times staff administer medication to residents in care. The interview with OS1 also revealed looking through R1’s MAR and saw it was not complete and secured a photo. An outside source interview and facility record reviews confirmed R1’s MAR was not complete.

Lastly, it was alleged that facility staff did not allow residents to have visitors during reasonable hours. An Outside Source 1 (OS1) Interview, LPA observation, and facility records reviews revealed the facility changed their visitation hours to 9:00 a.m. through 5:00 p.m. without any notice. An interview with OS1 revealed they had previously visited the facility outside the newly imposed visitation hours without any issue. OS1 also revealed coming to the facility at approximately 6:30 p.m. and was denied visitation. On March 2, 2023, the Department conducted an unannounced visit to the facility and observed a sign with visitation hours of 9:00 a.m. to 5:00 p.m. had been posted on the front door to the facility confirming the allegation. [See LIC 811 for Confidential Names]

Based on evidence obtained, the allegations are substantiated because the preponderance of the evidence standard has been met. Deficiencies are being cited in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, and listed on the 9099D.



An exit interview was conducted with Caregiver Diaz who was notified a copy of this report along with the LIC 9099D and Licensee/Appeals Rights (LIC 9058 01/16) will be provided at the conclusion of the visit. Signature below confirms receipt of the documents.



This is an amended version of the report dated 02/28/2024.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20230224152348
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: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
CCR
87465(A)(1)
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Incidental Medical and Dental Care. A plan for...medical...care shall be developed by each facility. The plan shall ... provide...obtaining such care, compliance with...the Licensee shall arrange...medical...care appropriate to the conditions and needs of residents.

This requirement was not met as evidenced by:
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Facility staff will attend a CCL approved training on when to obtain or arrange medical care for residents in care based on their health, physical, or mental conditions.

Licensee will provide proof of completion by POC due date.

This is amended version of the report dated 02/28/2024.
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Based on interviews and records reviews the Licensee did not arrange medical care for Resident 1 (R1) that was appropriate to their condition.

This posed a potential health risk to 1 out of 6 residents in care.
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Type B
03/28/2024
Section Cited
CCR
87465(e)(1-4)
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Incidental Medical and Dental Care. For every prescription and... PRN medication for which the licensee provides...shall be a signed... order....and label shall contain...The specific symptoms... hours between doses... maximum...doses allowed in...24-hour.

This requirement was not met as evidenced by:
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Facility staff will attend a CCL approved training on medication management and implement a tracking system to ensure all resident's MAR are complete at the end of each shift.

Licensee will provide proof of completion by POC due date.
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Based on interviews and records reviews the Licensee did not maintain a signed written order for Resident 1 [R1] in care.

This posed a potential health risk to 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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
02/24/2023 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20230224152348

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
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Caregiver Christopher DiazTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff neglect resulting in serious injury.
INVESTIGATION FINDINGS:
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3
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5
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7
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10
11
12
13
Licensing Program Analyst (LPA) Correia conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Caregiver Christopher Diaz.

The Department’s investigation included staff, resident, and outside source interviews. The investigation also included facility and outside source records reviews, and a facility tour.

It was alleged that staff neglect resulted in Resident 1 (R1) sustaining a serious injury. An interview with Staff 1 (S1) revealed on February 22, 2022, S1 had just brought R1 to their room and asked R1 to remain in their wheelchair while they assisted another resident. At approximately 6:30 p.m., S1 briefly went to assist another resident, and Staff 2 (S2) was working in the kitchen when both staff heard R1yell for help. Upon arrival to R1’s room, S1 and S2 found R1 on the floor. S1 and S2 conducted a full body assessment and then assisted R1 up from the floor and placed R1 in their bed. Interviews with S1 and S2 also revealed they observed a lump on R1’s head but there was no bleeding. Staff then notified the Licensee and R1’s POA who told staff they were on their way to 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: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20230224152348
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: 02/28/2024
NARRATIVE
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An interview with Outside Source 1 (OS1) revealed R1 was in their wheelchair and reached for something causing them to fall out of their wheelchair.

Based on facility staff and outside source interviews the allegation was 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 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 JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230224152348
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: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
CCR
87468.1
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11)To have their visitors, in...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.

This regulation was not met as evidenced by:
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At the time of the initial visit LPA consulted with Licensee and at the time of visit Licensee removed visitation signs from facility door. Visitation is allowed per plan of operation protocol.

Deficiency is cleared.


This is amended version of the report dated 02/28/2024.
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Based on interviews and observations Resident 1 [R1] in care was not afforded a reasonable level of visits at the facility.

This posed a potential personal rights risk to [R1] 1 out of # in care.
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HSC
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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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6