374604192-8-28-2023-08-AS-LTEZ-CV5UYW-20230828160037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604192
Report Date: 08/07/2023
Date Signed: 08/28/2023 03:57:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
12/29/2022 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20221229131315

FACILITY NAME:	OCEANSIDE REST HOME, INC		FACILITY NUMBER:	374604192
ADMINISTRATOR:	NAVASAK, SIERA		FACILITY TYPE:	740
ADDRESS:	4451 SAN JOAQUIN STREET		TELEPHONE:	(760) 822-6182
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Siera Navasak, Administrator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff restrained resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced subsequent visit, to deliver findings regarding the above prior complaint allegation. LPA was welcomed by and identified herself to caregiver Victoria Phongpaphanh. LPA then met with and discussed the purpose of the visit with Administrator Siera Navasak.

On 12/29/22 it was alleged that staff restrained a resident. The Department's investigation involved two unannounced facility visits/welfare check, review of facility records, interviews with relevant staff, residents, and outside sources.

Regarding the first allegation, "Staff restrained resident", it was alleged that S1 (see LIC811 Confidential List of Names) physically restrained R1 from leaving the facility, causing injury. Staff interview revealed that the staff member in question was terminated in October 2022 for similar violations of residents' personal rights; this was confirmed by review of facility records.
Continued on LIC9099-C (This is an amended report for signature only).

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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 4

Control Number 08-AS-20221229131315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME, INC	FACILITY NUMBER: 374604192
	VISIT DATE: 08/07/2023

NARRATIVE

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Continued from LIC9099

Staff interviewed observed the prior personal rights violations of S1, confirming R1 and R2 to be valid historians. 2 of 4 outside sources interviewed had knowledge of prior allegations against the staff in question, but did not have knowledge or observation of this incident. Resident interview revealed detailed information regarding the incident and R1 confirmed that there were no witnesses and they did not make anyone aware of the incident.

Records review showed that previous personal rights allegations were made against the staff in question, which was investigated and substantiated by the Department.

Based on interviews and records, the preponderance of evidence has been met, therefore the allegation is substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Administrator. An exit interview was conducted with Siera 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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
12/29/2022 and conducted by Evaluator Nacole Patterson

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20221229131315

FACILITY NAME:	OCEANSIDE REST HOME, INC		FACILITY NUMBER:	374604192
ADMINISTRATOR:	NAVASAK, SIERA		FACILITY TYPE:	740
ADDRESS:	4451 SAN JOAQUIN STREET		TELEPHONE:	(760) 822-6182
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Siera Navasak, Administrator		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff did not ensure medical evaluation for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA was welcomed by and identified herself to caregiver Victoria Phongpaphanh, then met with and discussed the purpose of the visit with Administrator Siera Navasak.

On 12/29/22 it was alleged that staff did not ensure a medical evaluation for a resident. Staff and residents interviewed did not corroborate the allegation due to no one witnessing the incident. Outside sources interviewed did not have knowledge or observation of the incident in question. Records review showed no submission of incident reports for the situation in question, injury to the resident, or medical care obtained for the resident. Interview with R1 revealed that they suffered no injuries from the incident and did not require medical care.
Based on interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Siera Navasak, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20221229131315

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME, INC	FACILITY NUMBER: 374604192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/07/2023 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	87468.1(a)(6) "Residents in all residential care facilities for the elderly shall have all of the following personal rights: …To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night." This requirement is not met, evidenced by	1 2 3 4 5 6 7	Immediate risk has been removed, LPA verified with the Licensee that S1 is no longer working at the facility as of 10/5/2022. Licensee will conduct an in-service training on personal rights, and abuse training for staff on and provide sign in sheets to the Department by POC due date.
	8 9 10 11 12 13 14	Based on records and interviews, Licensee's employee (S1) physically restrained resident (R1), preventing them from leaving the facility. This posed a potential safety risk to 1 of 1 clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Nacole Patterson	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC9099 (FAS) - (06/04)

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