374603846-6-2-2023-08-AS-ARAZ-CSEPHC-20230602111942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603846
Report Date: 06/02/2023
Date Signed: 06/02/2023 11:19:54 AM

Document Has Been Signed on 06/02/2023 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	OCEANSIDE HOUSE-ADULT RESIDENTIAL FACILITY, THE		FACILITY NUMBER:	374603846
ADMINISTRATOR:	CURRY, AMY		FACILITY TYPE:	735
ADDRESS:	658 MICHAEL STREET		TELEPHONE:	(760) 529-4233
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 4		CENSUS: 1	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator Amy Curry		TIME COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA) conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with administrator Amy Curry. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all must be ambulatory. There was a total of one (1) client in care who was ambulatory.

LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 110 F, bathroom #1 sink was 110 F and bathroom #2 was 109 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

No pools or bodies of water on the premises. Per administrator, there is one firearm kept at the facility locked and secured. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE HOUSE-ADULT RESIDENTIAL FACILITY, THE	FACILITY NUMBER: 374603846
	VISIT DATE: 06/02/2023

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[CONTINUED FROM LIC 809]

LPA interviewed staff and reviewed multiple staff and client records/files. LPA was unable to interview the client due to the client being at day program when inspection was conducted. LPA interviews did not raise any licensing concerns. One (1) out of three (3) staff files (S1) was missing Health screening report (LIC503). The files which LPA reviewed contained all other required documents. Confidential records were stored in locked area.

Deficiencies were cited during today's annual inspection; plan of correction was created with administrator.

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

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2023 11:19 AM - It Cannot Be Edited

Created By: Alyssa Ramirez On 06/02/2023 at 11:10 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE HOUSE-ADULT RESIDENTIAL FACILITY, THE	FACILITY NUMBER: 374603846
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 3 staff (S1) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Adminstrator will ensure that S1 has completed Health Screening Report (LIC503)with TB test and will place form in S1's staff file. Adminstrator will also email completed form to LPA Ramirez by POC due date.

Type A

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 3 staff (S1) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Adminstrator will ensure that S1 has completed Health Screening Report (LIC503) with TB test and will place form in S1's staff file. Adminstrator will also email completed form to LPA Ramirez by POC due date.

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 Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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