374604300-10-7-2026-08-AS-AGOH-DYN3ZK-20261007184141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 10/07/2026
Date Signed: 10/07/2026 06:42:00 PM

Document Has Been Signed on 10/07/2026 06:42 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	OCEANSIDE SENIOR LIVING		FACILITY NUMBER:	374604300
ADMINISTRATOR/ DIRECTOR:	SHANNON HUNDLEY		FACILITY TYPE:	740
ADDRESS:	5508 AVENIDA PACIFICA WAY		TELEPHONE:	(760) 978-6602
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 165		CENSUS: 104	DATE:	10/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:25 PM
MET WITH:	Executive Director Wes Hebner		TIME VISIT/ INSPECTION COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Wes Hebner. The facility's license shows a maximum capacity of one-hundred-and-sixty-five (165) non-ambulatory residents, six (6) of which may be bedridden. Per the fire clearance, only rooms 1102, 2101, 3102, 4101, 5101, and 5102 are approved for bedridden. The facility is approved for delayed egress doors and a hospice waiver for fifteen (15). During today’s inspection there were one-hundred-and-four (104) residents in care, with nine (9) currently on hospice. LPA and Executive Director Hebner toured the interior and exterior of the facility and inspected all common areas and a sample of occupied and unoccupied resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Sampled hot water temperature at taps accessible to clients were all compliant: a unit bathroom sink on the 1st floor of building 1 read at 111.6F, a unit restroom on the 2nd floor of building 1 read at 113.2F, and a unit restroom sink in the memory care unit (building 5) tested at 114.4F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were stored in the kitchen, which is locked when not in use. [Continued on LIC 809-C]

Sabel Martinez
Arian Golbakhsh
	DATE: 10/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE SENIOR LIVING	FACILITY NUMBER: 374604300
	VISIT DATE: 10/07/2026

NARRATIVE

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[Continued from LIC 809]

No toxic chemicals or poisons were accessible to clients. Laundry rooms were available for resident use in the Assisted Living community, but locked in the Memory Care unit. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Executive Director Hebner, no firearms or ammunition are kept at the facility.

Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months, dated for September 2026. LPA observed that the next quarterly staff emergency drill was scheduled for the end of October, but the facility was unable to provide record of previous emergency drills conducted under prior administration. One Technical Violation (TV) was issued and discussed. First aid kits in multiple buildings were complete and readily accessible. Required licensing postings were observed in visible areas of the facility; multiple copies were noted to be present.

LPA interviewed two (2) staff and one (1) client, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained most required documents. Confidential records were stored in locked areas. While reviewing the staff roster, LPA noted that one staff member (identified as S1) was not associated to the facility.

Review of the Guardian background check database revealed S1 did have an eligible background clearance, just that they were not associated to the facility. Per review of S1's association history, they were previously associated to the facility in March 2021 then removed in March 2026. Interview with Administrative staff revealed the individual who removed S1 from the roster was a former administrative staff member. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for S1 working at facility without having their clearance associated to the facility. In addition, a Civil Penalty is being assessed for the total amount of $500.00. Details are noted on the attached LIC 421BG form. The facility was able to associate S1 to the facility roster during the visit.

[Continued on LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/07/2026 06:42 PM - It Cannot Be Edited

Created By: Arian Golbakhsh On 10/07/2026 at 05:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: OCEANSIDE SENIOR LIVING	FACILITY NUMBER: 374604300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring a staff member (S1) had their background clearance associated to the facility, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/21/2026
	Plan of Correction
1 2 3 4	Licensee immediately associated S1 to the facility roster. Licensee will conduct review of thee facility's roster to ensure it is up to date and submit proof to LPA by 10/21/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/07/2026 06:42 PM - It Cannot Be Edited

Created By: Arian Golbakhsh On 10/07/2026 at 05:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: OCEANSIDE SENIOR LIVING	FACILITY NUMBER: 374604300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review and interview, the licensee did not comply with the section cited above in ensuring a staff member (S2) had record of a Health Screening and negative TB test, which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/21/2026
	Plan of Correction
1 2 3 4	Licensee will submit proof of a health screening and TB test conducted for S2 and submit to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE SENIOR LIVING	FACILITY NUMBER: 374604300
	VISIT DATE: 10/07/2026

NARRATIVE

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[Continued from LIC 809-C]

Additionally, while conducting staff records review, it was revealed that a staff member (identified as S2) did not have a Health Screening and negative TB (Tuberculosis) test on file, as required. Interview with administrative staff revealed that the record may have been lost as the facility transitioned from one partnered health screening company to another. One Type B violation was issued for S2 not having record of a health screening with TB test, and details are noted on the attached LIC 809-D page.

Two (2) deficiencies were cited during the inspection, along with one Technical Violation. An exit interview was conducted with Executive Director Hebner to whom a copy of this report, the LIC 9102 (TV form), LIC 811 (Confidential Names List), and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/07/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026

LIC809 (FAS) - (06/04)

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