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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604326
Report Date: 09/14/2021
Date Signed: 09/14/2021 05:37:38 PM

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:OASIS VILLAGE CAREFACILITY NUMBER:
374604326
ADMINISTRATOR:SAHID, RAMLAFACILITY TYPE:
740
ADDRESS:3865 SHIRLENE PLTELEPHONE:
(619) 727-7335
CITY:LA MESASTATE: CAZIP CODE:
91941
CAPACITY:6CENSUS: 4DATE:
09/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Ramla Sahid, AdministratorTIME COMPLETED:
04:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced case management visit. LPA was granted entry into the facility by Carina Ruiz, Staff, to whom she disclosed the purpose of the visit. Abdiaziz Hussen, House Manager, and Ramla Sahid, Administrator, arrived a short time later, and LPA again explained the reason for the visit..

This visit was initiated due to a self-reported incident that occurred on September 12, 2021, in which Resident #1 (R1) [LIC 811 Confidential Names List was provided to identify the resident] was absent without leave (AWOL) from the facility and returned to the facility on the same day with no reported injuries.

During today's visit, LPA reviewed resident records and interviewed staff. LPA discovered that although R1 has a diagnosis of dementia and is able to ambulate on his/her own, licensee had no auditory device or other staff alert feature to monitor exits while the one staff who was present provided care to another facility resident. R1's Physician's Report indicates that he/she is not able to leave the facility unassisted; however, R1 was able to leave the facility undetected at approximately 10:00 AM and reach a neighboring street and residence before being located by the local police authority at approximately 10:45 AM. LPA did observe that licensee has an Absentee Notification Plan in place, and the plan was followed.

A deficiency is being cited during today's visit and is listed on an LIC 809-D. This report was discussed with Abdiaziz Hussen, House Manager, at the end of the visit. Copies of the report and Licensee/Appeal Rights will be provided to Ramla Sahid, via email, following the visit.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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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: OASIS VILLAGE CARE
FACILITY NUMBER: 374604326
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited

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Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based upon interviews conducted, R1 was able to leave the facility unassisted and
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without being detected, which posed a potential safety risk to R1, who was 1 of 5 residents in care.
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the POC due date of 9/24/2021

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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: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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