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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604174
Report Date: 05/25/2022
Date Signed: 05/31/2022 08:28:53 AM

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
02/13/2020 and conducted by Evaluator Iby Strong
COMPLAINT CONTROL NUMBER: 08-AS-20200213113443
FACILITY NAME:OCEAN BREEZE RETIREMENT VILLAFACILITY NUMBER:
374604174
ADMINISTRATOR:STEELE, ARSENIAFACILITY TYPE:
740
ADDRESS:93 AVENIDA DESCANSOTELEPHONE:
(760) 529-9559
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:0CENSUS: 0DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Report Mailed to Licensee via USPS Certified Mail TIME COMPLETED:
08:01 AM
ALLEGATION(S):
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Staff are mismanaging residents medication
Staff are not providing resident with accurate dose of medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Iby Strong sent this report to former licensee's last known mailing address via USPS certified mail.

On February 13, 2020 the Department received a complaint that facility was mismanaging medication and staff was not providing accurate dose of medication. During the Department’s investigation, records were reviewed, facility processes were observed, and staff were interviewed. During this process, it was revealed that medications were not managed properly. In a medication audit performed by the Department on February 19th, 2020, records were reviewed. These records revealed five out of five residents had medication issues. It was also observed that in individual medication bins four out of five resident's prescriptions were missing a pharmacy label, three out of five resident’s medication were missing from the medication bin and two out of five resident medications were not given according to physician's orders. Statements from staff also confirmed that the facility was not managing medication in accordance to established California Code of Regulations.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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 3
Control Number 08-AS-20200213113443
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 BREEZE RETIREMENT VILLA
FACILITY NUMBER: 374604174
VISIT DATE: 05/25/2022
NARRATIVE
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It is also alleged that staff were not providing residents with accurate dose of medication. During the Department’s record review on February 19, 2020 it was verified that two out of five residents were not receiving the correct dosage of medication as prescribed. Individual resident records also show that the medications were not issued according to prescription. Statements from staff also confirm that medications were not given according to physician’s orders. A facility file review did not reveal any adverse reactions occurred due to this mismanagement.

Based on the Departments review of facility, resident, and outside source records, as well as interviews with staff and observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D .A copy of this report and Appeal and Licensee Rights (LIC 9058 01/16) were provided to the former Licensee, Suzette Montellano, via USPS Certified Mail.

SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200213113443
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 BREEZE RETIREMENT VILLA
FACILITY NUMBER: 374604174
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87465(h)(4)
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Incidental Medical & Dental - All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is no met as evidenced by:
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Plan of Correction cleared as evidenced by facility closure, effective: 1/8/21. This deficiency has been cleared.
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Based on observations, interviews and records review, the licensee did not ensure all centrally stored medicaltion were labeled within compliance in 3 of 5 persons in care (R1, R2 and R3) which posed a potential health risk to persons in care.
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Type B
05/31/2022
Section Cited
CCR
87465(c)(2)
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Incidental Medical & Dental - ... Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:

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Plan of Correction cleared as evidenced by facility closure, effective: 1/8/21. This deficiency has been cleared.
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Based on observations, interviews and records review, the licensee did not administer medication according to physician's orders in 3 of 5 persons in care (R1, R2 and R3). This 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: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3