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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604143
Report Date: 11/19/2021
Date Signed: 11/21/2021 11:27:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
374604143
ADMINISTRATOR:JOHNSTON, SHERYLFACILITY TYPE:
740
ADDRESS:4500 CANNON RDTELEPHONE:
(760) 295-8515
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:140CENSUS: 95DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Executive Director, Sheryl Johnston and Resident Care Director, Joan GomezTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to follow up on incident reports received on November 4, 2021 and November 12, 2021. LPA Ryan introduced herself, stated the purpose of the visit, was allowed entry, and met with Executive Director, Sheryl Johnston

Community Care Licensing (CCL) received incident reports regarding Resident 1 (R1) and Resident 2 (R2) experiencing medication errors on separate occasions at the facility. The facility self-reported these incidents to CCL. During the visit, a medication error regarding Resident 3 (R3) was also reported.

During today's visit, LPA toured the facility, reviewed resident records, and interviewed staff and residents. A deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted with Sheryl Johnston and Joan Gomez. A copy of this report, along with the Licensee Rights (9058 01/16) was emailed to the executive director at the conclusion of the visit, an electronic response confirms the receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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
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: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited

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87455 Incidental Medical and Dental Care (c)(2)... the facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:...Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by;
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Based on interviews and records review, the facility staff did not administer medications as prescribed for 3 out of 95 residents,which poses a potential health risk to 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: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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