374603842-10-11-2024-08-AS-SJAB-DAAVER-20241022162246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603842
Report Date: 10/11/2024
Date Signed: 10/11/2024 08:42:34 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
08/21/2024 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20240821121136

FACILITY NAME:	OCEANSIDE ELDERLY CARE HOME 452		FACILITY NUMBER:	374603842
ADMINISTRATOR:	ALVI, MUHAMMED		FACILITY TYPE:	740
ADDRESS:	452 FOUSSAT RD		TELEPHONE:	(760) 529-9257
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	6	CENSUS: 0	DATE:	10/11/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Caregiver Christopher Diaz and Licensee Dr. Mohammed Rahman		TIME COMPLETED:	09:00 PM

ALLEGATION(S):

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-Licensee did not meet requirements regarding observation of resident.
-Licensee did not meet other reporting requirements.
-Licensee did not meet requirements related to resident room change.

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 and their staff did not provide needed observation to Resident #1 (R1), that Licensee did not meet reporting requirements related to incidents affecting R1, and that Licensee did not uphold R1’s personal rights as it related to a room change/transfer. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tours/welfare checks and interviews of pertinent facility staff and outside sources. The Department also reviewed relevant care records. LPA attempted to interview R1 and each of their housemates, 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:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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 8

Control Number 08-AS-20240821121136

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. Care records and interviews aligned to show that R1 was memory-impaired, wheelchair-bound, took blood-thinner medication, had very fragile skin, had a history of being prone to bruising and skin tears, 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, one of these managers also acknowledged that the overnight staff (who are alone on duty) were also allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 PM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were allowed to sleep. 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 was not being visually checked on.

According to caregiver interviews: Around 7:00 AM on 07-26-2024, Caregiver Staff #1 (S1), who had just started their work shift, went to R1’s bedroom and first observed that R1 had a raised bump on their forehead and a skin tear on their neck that had bled. While R1 was still in bed, there was some dried blood on their pillow, and several other pillows were on the floor beside their bed. Caregiver Staff #2 (S2) was the lone staff on duty during the preceding overnight shift. Per interview of S2: They had last checked on R1 around 5:00 AM, finding nothing out of the ordinary. They denied R1 having fallen out of bed. They did not have a clear explanation for R1’s injuries. They mentioned R1 briefly screamed when S1 was in the room alone with R1. LPA asked, but S2 did not believe that S1 harmed R1 during the encounter. Per interview of S1: They denied harming S1 or causing any skin injuries during the incident. S1 had asked S2 what had occurred prior to their own arrival at work, but S2 did not have an explanation for R1’s injuries. S1 photographed R1’s injuries and bedroom, then notified R1’s responsible person. LPA tried to interview R1 about the incident, but they had no memory of it. S1 and S2 said: R1 was also unable to state to them what had happened to them.

[CONTINUED ON LIC 9099-C, 2 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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 8

Control Number 08-AS-20240821121136

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]

LPA obtained multiple photographs (some of which were time and date-stamped), coming from multiple sources, which together showed: R1 initially had an abrasion and slightly raised bump on the middle of their forehead that was 1.5 inches wide by 1 inch long. This raised bump on R1’s forehead later lowered, and a bruise about 4 inches wide by 5 inches long formed in its place. R1 also had a bruise and a skin tear on their neck (that bled), and the blood had dried by the time it was discovered. There was also a small amount of dried blood on one pillow on R1’s bed. R1’s other four pillows were on the floor beside their bed. There was also a prominent wet stain on their bedsheet (resembling urine) about 4 feet wide by 1 foot long, where R1’s back would have been. Interviews of S1 and S2 had showed that R1 had been wearing their incontinence briefs at the time they were discovered in this condition, despite their bed being visibly wet.

Then around 08-06-2024, a skin tear developed on top of a pre-existing hematoma on R1’s lower right leg. (Per the National Institutes of Health, a hematoma is a pool of mostly clotted blood that forms in a body space, such as under the skin.) CCLD obtained before and after photographs of the hematoma intact, and the subsequent skin tear, showing that at one point, the open area of skin was around 2 inches long by 1.5 inches wide. LPA interviewed pertinent caregivers, which showed that while some were aware of this injury, all interviewed were also uncertain as to how it was caused.

Although R1’s 07-26-2024 and 08-06-2024 injuries were timely reported to R1’s responsible person, staff and outside source interviews clearly showed that Licensee did not notify either R1’s physician or R1’s nurse practitioner about the above incidents/injuries involving R1. By the time the complaint was filed and CCLD began investigating, R1’s forehead abrasion had healed, their forehead bruise had faded, their neck skin tear had healed, and their lower right leg skin tear had scabbed over and healed, yet 2 of 2 facility Licensees/managers and 2 of 5 caregivers (who directly cared for R1) interviewed were still unaware that these injuries to R1 had earlier occurred. There was also no written documentation of these specific injuries to R1 in the facility’s records, as was required. LPA reviewed the CCLD San Diego Regional Office’s files, finding that Licensee did not submit written incident reports regarding the above injuries to R1 (which was required to be done within seven days of incident occurrence). Incident reports were also required to be sent to R1's responsible person, and interviews showed that was also not done.

[CONTINUED ON LIC 9099-C, 3 of 3]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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 8

Control Number 08-AS-20240821121136

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]

Interviews of Licensees/managers, caregivers, and outside sources also confirmed: After an involuntary facility transfer (which CCLD cited during a separate complaint investigation), Licensee placed R1 into a certain bedroom at Oceanside Elderly Care Home 452 during late July 2024. However, around 08-02-2024, Licensee again moved R1, this time to a different bedroom within the facility, without providing advance written notice to R1’s responsible person or securing their consent. R1 was not cognitively capable of consenting to this room change. Per interviews of Licensees/managers and corroborated by LPA observation: R1 (who was an existing resident) was moved to a different room to make way for a brand-new resident who was moving in, and who themselves desired the bedroom that R1 was already occupying. Both bedrooms were private (non-shared) and there was no emergency which necessitated R1’s room change/transfer.

Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet requirements regarding observation of a resident, the Licensee did not meet reporting requirements, and that Licensee did not meet personal rights requirements related to a resident’s room change. These three (3) allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). 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 pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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 8

Control Number 08-AS-20240821121136

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 B 11/11/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible person, if any.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.
	8 9 10 11 12 13 14	Based on records and interviews, 1 of 5 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.	8 9 10 11 12 13 14
Type B 11/11/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."	1 2 3 4 5 6 7	Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had incidents which threatened their welfare/health, and Licensee did not submit a written report of the incidents to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons in care.	8 9 10 11 12 13 14

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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 8

Control Number 08-AS-20240821121136

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 B 11/11/2024 Section Cited CCR 87468.2(a)(16)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.”	1 2 3 4 5 6 7	As of the date of deficiency issuance, R1’s responsible person has decided to keep them in the same bedroom that they currently occupy (and to not go back to the former bedroom). Licensee agreed to not move R1 to a different room again, without first observing the regulatory requirement. Licensee agreed to observe the same for Resident #2 (R2). These actions resolve the deficiency.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 5 residents (R1) received written notice of room change at least 30 days in advance. The room change was not done with resident consent, or to fill a vacant bed, or due to an emergency. This posed a potential personal rights risk to persons 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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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: 6 of 8

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
08/21/2024 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20240821121136

FACILITY NAME:	OCEANSIDE ELDERLY CARE HOME 452		FACILITY NUMBER:	374603842
ADMINISTRATOR:	ALVI, MUHAMMED		FACILITY TYPE:	740
ADDRESS:	452 FOUSSAT RD		TELEPHONE:	(760) 529-9257
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	6	CENSUS: 0	DATE:	10/11/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Caregiver Christopher Diaz and Licensee Dr. Mohammed Rahman		TIME COMPLETED:	09:00 PM

ALLEGATION(S):

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Licensee did not meet background clearance requirements for staff.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. 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 did not ensure that Staff #4 and Staff #5, who worked as caregivers at the facility amongst residents, had the necessary background / criminal-record clearances with CCLD. CCLD’s investigation involved reviewing the facility’s employee roster against the Department’s background-clearance databases. LPA also conducted unannounced facility tours to interview facility Licensees and caregivers.

[CONTINUED ON LIC 9099-C]

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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: 7 of 8

Control Number 08-AS-20240821121136

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]

Per review of CCLD’s Guardian and Licensing Information System (LIS) databases, during the time frame of the complaint allegation, both S4 and S5, as well as all other current facility staff, were each fingerprinted and possessed active background clearances to work. Interviews of Licensees/managers and facility staff reiterated the same.

Based on record review and interviews, the allegation that Licensee’s staff did not have current background / criminal-record clearances is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was issued for it.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
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: 8 of 8