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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604192
Report Date: 03/03/2023
Date Signed: 03/03/2023 04:16:11 PM


Document Has Been Signed on 03/03/2023 04:16 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:OCEANSIDE REST HOME, INCFACILITY NUMBER:
374604192
ADMINISTRATOR:NAVASAK, SIERAFACILITY TYPE:
740
ADDRESS:4451 SAN JOAQUIN STREETTELEPHONE:
(760) 822-6182
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
03/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Licensee Siera NavasakTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Caregiver Lucy Credito. LPA then met and discussed the purpose of the visit with Licensee Siera Navasak.

Today's visit was in response to an LIC624 Unusual Incident/Injury Report, which licensee self-submitted to the CCLD San Diego Regional Office on 02/23/2023, involving Resident #1 (R1) and Staff #1 (S1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed facility tour / welfare check, interviewed 6 of 6 residents in care, interviewed staff, and collected records. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Navasak, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
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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