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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604192
Report Date: 08/16/2023
Date Signed: 08/16/2023 05:48:06 PM


Document Has Been Signed on 08/16/2023 05:48 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:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Caregiver Brandon Navasak and Administrator Siera NavasakTIME COMPLETED:
06:00 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 Brandon Navasak. LPA then met and discussed the purpose of the visit with Licensee Siera Navasak, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 05/31/2023, 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 a facility tour and welfare check, interviewing R1 and verifying that they were safe and uninjured. LPA also collected pertinent records and interviewed relevant staff.

Records and interviews showed: While S1 assisted R1 in the shower on 05/29/2023, S1 cut R1’s hair, against their will and protest. This caused R1 to be sad/upset. When licensee interviewed S1 about the incident, S1 admitted to doing this. Also, during one prior occasion in late 2022, Staff #2 (S2) had also cut R1’s hair, against their will. Personnel records showed that licensee had disciplined S1 and S2, following each respective incident. As of the date of LPA’s site visit, neither S1 nor S2 were still employed at the facility.

A preponderance of evidence exists to show that licensee’s staff (S1 and S2) did not treat a resident (R1) with dignity. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Since the deficiency is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). A Plan of Correction was jointly developed with the licensee.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/16/2023 05:48 PM - It Cannot Be Edited

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: OCEANSIDE REST HOME, INC
FACILITY NUMBER: 374604192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...”
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Records and interviews showed S1’s employment was terminated on 05/31/2023, and S2’s employment was terminated on 10/05/2022. Licensee agreed to utilize a third-party source to retrain their direct care staff on Resident’s Personal Rights (see Regulation 87468.1 and 87468.2). Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1 and S2) did not treat 1 of 6 residents (R1) with dignity, which posed a potential personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: OCEANSIDE REST HOME, INC
FACILITY NUMBER: 374604192
VISIT DATE: 08/16/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

An exit interview was conducted with Siera Navasak, to whom a copy of this report, the LIC 809-D, the LIC 421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3