374604143-9-6-2023-08-AS-DPOL-CW3SN5-20230927140100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604143
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:43:36 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
09/14/2020 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20200914151143

FACILITY NAME:	OCEAN HILLS ASSISTED LIVING & MEMORY CARE		FACILITY NUMBER:	374604143
ADMINISTRATOR:	KURT NORDEN		FACILITY TYPE:	740
ADDRESS:	4500 CANNON RD		TELEPHONE:	(619) 865-2614
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	123	CENSUS: 116	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Sheryl Johnston, Executive Director		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Resident was left unattended for extended period of time resulting in resident's hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to deliver findings for a complaint investigation. LPA was granted entry by Sheryl Johnston, Executive Director (ED), after identifying herself. LPA discussed the purpose of the visit and the basic element of the allegation mentioned above with ED.

On September 14, 2020, it was alleged that Resident 1 (R1) was left unattended for an extended period of time resulting in resident’s hospitalization. During today's visit, LPA toured the facility, reviewed facility records, and interviewed facility staff.

On September 7, 2020, facility records indicated that R1 was last seen by staff around 2:30PM. R1 was prescribed medication to be taken at 4:00PM and given by Staff 1 (S1). S1 admitted to facility that they

[Continued on LIC9099-C, Page 1 of 2]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200914151143

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: OCEAN HILLS ASSISTED LIVING & MEMORY CARE	FACILITY NUMBER: 374604143
	VISIT DATE: 09/06/2023

NARRATIVE

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did not see R1 at 4:00PM because S1 usually gave R1 their 4:00PM medication at 8:00PM. Records also indicated an outside source asked S1 to check on R1 sometime between 6:00PM and 7:00PM. At that time, S1 did not check on R1. Outside source called a second time, around 7:10PM, prompting S1 to check on R1 and finding them unresponsive. Facility self-reported that paramedics were called immediately, and responsible party was notified. On September 15, 2023, S1 was terminated by facility.

Based on the evidence obtained during the complaint investigation, the allegations that resident was left unattended for extended period of time resulting in resident's hospitalization is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with ED. An exit interview was conducted with ED; a copy of this report and Licensee's Rights (LIC9058) were provided.

[Continued on LIC9099, Page 2 of 2]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20200914151143

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: OCEAN HILLS ASSISTED LIVING & MEMORY CARE	FACILITY NUMBER: 374604143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	ADDITIONAL PERSONAL RIGHTS: (a) … residents … shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs ... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	S1 was terminted on 09/15/20.
	8 9 10 11 12 13 14	Based on interview and record review the licensee did not provide care, supervision, and services in 1 of 80 persons in care (R1) which poses a potential Health or Safety risk to persons in care.	8 9 10 11 12 13 14
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	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: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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