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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603842
Report Date: 10/11/2024
Date Signed: 10/11/2024 08:50:57 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
09/13/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240913120439
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 452FACILITY NUMBER:
374603842
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:452 FOUSSAT RDTELEPHONE:
(760) 529-9257
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 6DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Caregiver Christopher Diaz and Licensee Dr. Mohammed RahmanTIME COMPLETED:
09:00 PM
ALLEGATION(S):
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-Licensee neglect, contributing to skin breakdown.
-Licensee did not maintain comfortable facility temperature.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit.

The Complainant alleged that Licensee neglect contributed to the development of a pressure injury on Resident #1’s (R1’s) buttock during August 2024. [LIC811 Confidential Names List for a description of select person identifiers used in this report.] They also alleged that on 09-08-2024, Licensee did not maintain the facility at a comfortable temperature. CCLD’s investigation involved an unannounced facility tours/welfare checks and interviews of pertinent staff and outside sources. The Department also reviewed relevant care records. LPA attempted to interview R1 and each of their housemates about the above allegations, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. [CONTINUED ON LIC 9099-C, 1 of 3]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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 5
Control Number 08-AS-20240913120439
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 452
FACILITY NUMBER: 374603842
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Available care records on R1 and interviews of staff and outside sources aligned to show that R1 was memory-impaired, wheelchair-bound, wore incontinence briefs, and required staff assistance with mobility, transferring, and incontinence care, among other tasks.

According to interviews of Licensees/managers, facility caregivers usually checked residents’ briefs at least once every two (2) hours, changing them if they are wet or soiled. However, Licensees/managers also acknowledged that the overnight staff (who are alone on duty) were allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 AM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were not checking on residents. Caregiver interviews varied slightly, but they generally corroborated that there was usually a window of between four (4) to six hours (6) during the overnight shift when R1’s briefs were not being checked and changed.

LPA obtained multiple photographs from multiple sources, which together showed: On 08-02-2024, the skin on the area in question on R1’s buttock was closed/intact. On 08-30-2024, the top layer of skin over this same spot was broken, indicating a pressure injury had developed on R1’s buttock. There was also a small black scab inside the broken skin area.

LPA also obtained a photograph, which showed during the morning of 07-26-2024, staff did not provide timely needed incontinence care to R1, as evidenced by R1’s bedsheet/mattress being visibly wet with urine (the wet spot was 4 feet by 1 foot) where R1’s back would have been. Interviews of 2 of 2 staff showed that R1 had been wearing an incontinence brief at the time they discovered them in this condition.

Medical records and outside source interviews showed on 08-30-2024, R1’s PCP gave a telephone order (which R1’s NP transcribed into writing for facility staff), instructing them to perform the following interventions: Reposition/rotate R1’s body weight when in bed every two (2) hours, change R1’s incontinence briefs as soon as it is soiled, and apply Calmoseptine and Vitamin A&D ointments to R1’s buttocks.

[CONTINUED ON LIC 9099-C, 2 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240913120439
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 452
FACILITY NUMBER: 374603842
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 3]

By 09-02-2024, a subsequent photograph showed the top layer of skin over the affected area on R1’s buttock was still open but had overall improved / showed signs of healing. Interview of outside sources showed that by 09-04-2024, the NP visited the facility to inspect R1, at which point the top layer of skin over the affected area on R1’s buttock had closed/healed, with just minor redness remaining.

Review of records, confirmed by manager interview, confirmed: During the complaint allegation time frame, and even at the start of CCLD’s complaint investigation on 09-17-2024, Licensee did not possess either an LIC603 Pre-Placement Appraisal (or equivalent pre-admission care appraisal document) or an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”) on R1, as were required. [CCLD cited these issues via a separate Case Management report.] Licensees/managers were still unaware that R1 had an earlier pressure injury on their buttock, or that R1’s physician gave new orders on 08-30-2024, despite the overall improvement/healing in R1’s skin condition since that time.

LPA also obtained multiple photographs of the facility’s internal digital thermometer (which had a built-in date and time display). Together, they showed: On Friday 09-06-24 around 8:04 PM, the facility’s interior air temperature was 84 F. On 09-07-2024 around 5:49 PM, the facility’s interior air temperature was 85 F. Then on 09-08-2024, around 3:39 PM, the facility’s interior air temperature was 87 F. During his 09-17-2024 site visit, LPA inspected and tested the above thermometer, comparing it against a traditional mercury-based thermometer and an infrared hand-held thermometer. LPA confirmed that the facility’s internal digital thermometer was correctly calibrated and accurate in terms of displayed temperature, date, and time.

LPA also reviewed historical data from Weather.com for Zip Code 92054 (where the facility is located), finding: On Thursday 09-05-24, a daily high of 90 F was reached. On Friday 09-06-24, a daily high of 97 F was reached. On Saturday 09-07-24, a daily high of 93 F was reached. On Sunday 09-08-24, a daily high of 101 F was reached. On Monday 09-09-24, a daily high of 94 F was reached. On Tuesday 09-10-24, a daily high of 85 F was reached. On Wednesday 09-11-24, a daily high of 78 F was reached.


[CONTINUED ON LIC 9099-C, 3 of 3]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240913120439
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 452
FACILITY NUMBER: 374603842
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 2 of 3]

According to regulation, RCFE Licensees “shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F." Interviews of an outside source showed that residents were indeed uncomfortably hot on 09-08-2024. Although the ambient outside temperature peaked on 09-08-2024 (the subject date of the complaint allegation), Zip Code 92054 still did not meet criteria for being an overall “area of extreme heat.” According to the Federal Emergency Management Agency (FEMA), “extreme heat conditions” in California are defined as “three days over 100 F.” Licensee thus remained responsible for ensuring that the facility’s internal air temperature was both “comfortable” and not in excess of 85 F during the allegation time frame.

Interviews of facility Licensees/managers and outside sources, corroborated by written correspondence, showed: The facility did not have central air conditioning during the allegation time frame (nor was Licensee required to maintain such). During the afternoon of 09-08-2024, residents’ responsible persons contacted Licensees via phone with concerns regarding the heat inside the facility. While Licensees/managers timely replied via phone, they did not personally visit the facility that same day, or alert CCLD to the situation. It was not until the next day (09-09-2024) that Licensee’s staff brought two (2) more portable air conditioning units to the facility, at which point the interior of the facility had significantly cooled. During his 09-17-2024 welfare check, LPA observed multiple portable cooling units at the facility; the temperature was comfortable on that date.

Based on records and interviews, a preponderance of evidence exists to show that Licensee neglect (regarding incontinence care) contributed to R1 developing a pressure injury, and that there was a day when Licensee did not maintain the facility at a comfortable temperature. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). The Department determined that one of the violations resulted in injury to a resident in care. An Immediate Civil Penalty of $500.00 was thus charged and is noted on the LIC421-IM page. Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240913120439
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 452
FACILITY NUMBER: 374603842
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2024
Section Cited
CCR
87652(b)(3)
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87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1’s pressure sore has healed, resolving the immediate risk. Licensee agreed to hire (if needed) and employ additional overnight staff, such that there is daily at least one overnight awake staff on duty, for as long as there are residents at the facility who rely on staff for both mobility and incontinence care. The purpose of this is to ensure that all residents’ incontinence products will be visually checked (and if needed, changed), and those residents’ body weight can be rotated/redistributed in bed, approximately once every two (2) hours, around the clock (24/7). Licensee agreed to E-mail an updated form LIC500 Personnel Report, reflecting these changes, plus proof that caregivers were retrained on resident skin care and managed incontinence care, to LPA, by 11-11-2024. The LIC500 should realistically consider the sleep/rest needs of all staff.
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Based on interviews and photographic evidence: For 1 of 5 residents (R1), who was incontinent, Licensee did not ensure that they were kept clean and dry. This posed an immediate health and personal rights risk to persons in care.
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Type B
10/11/2024
Section Cited
CCR
87303(b)(2)
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87303 Maintenance and Operation: “(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F…and 85 degrees F…” This requirement was not met, as evidenced by:
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By the date of deficiency issuance, Licensee had already brought and left additional portable cooling units to the facility. This action resolved the deficiency. The Plan of Correction is Satisfied.
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Based on records and interviews, Licensee did not at all times maintain a comfortable temperature for residents, by cooling rooms to a comfortable range between 78 degrees F and 85 degrees F. This posed a potential health and personal rights risk to 5 of 5 residents (R1 through R5) 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5