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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604143
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:15:35 PM


Document Has Been Signed on 06/09/2022 04:15 PM - It Cannot Be Edited

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: 103DATE:
06/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Joan GomezTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit to Resident Services Director Joan Gomez.

The Department received an incident report from the facility on 5/13/2022 stating that Resident 2 (R2) complained of pain and discomfort and staff observed swelling and a bruise on R2's foot. [Joan was provided with an LIC811 Confidential Names list to identify individuals] Staff provided R2 with pain medication and applied an ice pack to R2's foot as tolerated. R2 was sent to the hospital after the foot was observed to be worsening. R2 was diagnosed with a fractured foot at the hospital.

During today's visit, LPA toured the facility, observed residents in care, reviewed facility records, and interviewed staff.

No deficiencies were cited or observed on this date. An exit interview was conducted with Resident Services Director Joan Gomez, to whom a copy of this report and the licensee appeal rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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