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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604483
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:01:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/06/2022 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20221206114840
FACILITY NAME:SHORESIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
374604483
ADMINISTRATOR:KAHNIS, KEVINFACILITY TYPE:
740
ADDRESS:1911 S FREEMAN STTELEPHONE:
(442) 266-2107
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:3CENSUS: 3DATE:
01/31/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Quetzali Kahnis, AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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- Resident(s) were restrained.
- Facility did not provide residents with clean linens.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez and Licensing Program Manager (LPM) Denise Powell conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA and LPM identified themselves and were granted entry by Quetzalli Kahnis, Administrator. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administrator Kahnis.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review of relevant documents pertinent to this investigation, and LPA observation of the facility grounds.

It was alleged that there was a resident who was restrained. Specifically, there was a resident who was restrained throughout the night to the bed. Interviews were inconsistent. An interview with an outside source maintained that there was a resident who used a belt throughout the night for safety reasons.

(Continuation on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
VISIT DATE: 01/31/2023
NARRATIVE
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Interview with the Administrator said that they did not have a resident who used a restraint. A review of residents’ records revealed that there were no residents who had an approved physician’s order for a postural support. During a tour of the facility on 12/13/2022, LPA observed the bed and did not see a belt on or near the residents’ bed or on any of the residents. There is not sufficient evidence to support the allegation.

It was alleged that the facility did not provide residents with clean linens. Specifically, that the residents were only provided clean linens in preparation for a visit. Interviews with outside sources were not able to corroborate the allegation. Interview with the Administrator said that the linens were changed on a weekly basis. During a tour of the facility on 12/13/2022, LPA observed that the linens were clean and in good condition. Based on the evidence and observations obtained, there is not sufficient evidence to confirm the allegation.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is not sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.

An exit interview was conducted with Administrator Kahnis. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Administrator Kahnis at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/06/2022 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20221206114840

FACILITY NAME:SHORESIDE VILLA ASSISTED LIVINGFACILITY NUMBER:
374604483
ADMINISTRATOR:KAHNIS, KEVINFACILITY TYPE:
740
ADDRESS:1911 S FREEMAN STTELEPHONE:
(442) 266-2107
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:3CENSUS: 3DATE:
01/31/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Quetzali/Kevin Kahnis, Licensee/AdministratorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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9
- Facility did not provide sufficient numbers of staff for residents’ care needs.
- Facility did not provide residents with enough food.
- Facility in disrepair.
- Call pendants were deactivated by staff.
- Licensee did not afford resident(s) with privacy.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez and Licensing Program Manager (LPM) Denise Powell conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA and LPM identified themselves and were granted entry by Quetzalli Kahnis, Administartor. LPA stated the purpose of the visit and reviewed the findings of the complaint with Administarttor Kahnis.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review of relevant documents pertinent to this investigation, and LPA observation of the facility grounds. On December 6, 2022, it was alleged that the facility did not provide sufficient numbers of staff for residents’ care needs; facility did not provide residents with enough food; facility in disrepair; call pendants were deactivated by staff; and Licensee did not afford resident(s) with privacy.

(Continuation on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
VISIT DATE: 01/31/2023
NARRATIVE
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On December 6, 2022, it was alleged that the facility did not provide sufficient numbers of staff for residents’ care needs. Specifically, it was alleged that staff would leave residents alone to tend residents at another facility next door on multiple occasions. Interview with an outside source said that they recalled two staff who worked throughout the day. The first staff worked from 7:00 AM to about 5:00 PM. The Administrator would then relieve that staff. Interview with Administrator stated that they currently have one staff who works the 7:00 AM – 4:00 PM shift. Administrator stated that they relieved that staff and work from 4:00 PM - 10:00 PM. Administrator also confirmed that there is no awake staff who work the overnight shift from 10:00 PM – 3:00 AM. According to the Administrator, the Licensee would conduct rounds starting at 3:00 AM until the morning shift arrived. Interview with outside sources confirmed that there was only one staff person assisting residents at both facilities. The staff would assist residents at the facility, then leave the facility to tend to residents at the facility next door. Outside sources said that there were never more than one staff person observed at the facility. Staff schedules were not provided during the course of the investigation. A review of resident records revealed that the residents needed staff assistance with incontinence care needs and other activities of daily living. Based on the evidence obtained during the investigation, there is sufficient evidence to support the allegation.

It was alleged that the facility did not provide residents with sufficient food. Specifically, it was alleged that there was insufficient food supply to make residents food. Interview with the Administrator revealed that they purchase groceries on a weekly basis on Monday’s, but was unable to go that Monday, December 12, 2022. LPA was provided a grocery list with an unknown date, including grocery receipts. The receipts provided ranged from October 24, 2022 – December 7, 2022. No sample menus were available or provided during the investigation. During a tour of the facility on December 13, 2022, LPA observed that the facility was low on perishable food supply for residents in care, including no fresh fruits or available snack items. Based on the information and the evidence obtained during the investigation, there is enough evidence to support the allegation.

It was alleged that the facility was in disrepair. Specifically, the toilet was leaking water and the water was brown in color due to rusted pipes.

(Continuation on LIC9099-C)
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
VISIT DATE: 01/31/2023
NARRATIVE
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During a tour of the facility on December 13, 2022, LPA did not observe discoloration in the water, but did observe the water leak behind the toilet area under the shut off valve. LPA observed that there was a plastic container under the valve that held the water that leaked out of the valve. Interview with the Administrator said that the contractor who had worked on the facility, would work on the leak in the bathroom. Administrator was unable to communicate how long the leak had been happening; however, observations showed visible water stains and discoloration on bathroom wall behind toilet.

It was alleged that the call pendants for residents to request assistance were deactivated by staff. Specifically, it was alleged that the call buttons were turned off throughout the night. During a tour of the facility on December 13, 2022, LPA pressed two individual call buttons and confirmed that both of the call pendants were turned off. According to an interview with the Administrator, the call pendants were routinely being turned off during the day, since there was a staff working throughout the day. Interviews with outside sources confirmed call pendants were also being routinely turned off by staff at night. Based on evidence obtained, there is sufficient evidence to support the allegation.

It was alleged that the facility did not afford residents with privacy. Specifically, it was alleged that there were cameras inside the resident’s room. Interview with the Administrator revealed that the facility is allowed to have cameras throughout the facility. LPA also directly observed a camera in the bedroom on December 13, 2022. LPA confirmed a camera set up on top of a dresser in a shared bedroom with resident #1 (R1) and resident #2 (R2), facing R1's bed. The camera was quickly disconnected by the Administrator. Record reviews determined there was no resident consent or indication of prior Department approval on file for use of video surveillance in a private area. Based on observations and records review, there is sufficient evidence to support the allegation.

The above-mentioned allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Administrator, Kahnis. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Administrator Kahnis at the conclusion of the visit. The signature below confirms the receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited
CCR
87411(a)
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87411 (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the
services necessary to meet resident needs… this requirement was not met as evidenced by:
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Facility will hire additional staff and submit a staff schedule to LPA by POC due date, 02/07/2023.
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Based on interviews and records review, the Licensee did not have night staff assigned to the facility for residents who have dementia. This posed a potential health risk to one of three residents in care.
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Type B
02/14/2023
Section Cited
CCR
87555(b)(3)
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87555 General Food Service Requirements- Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician… this requirement was not met as evidenced by:
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A sample menu was provided during the visit and facility will be continue to shop weekly. Adequate food items were observed during the visit. POC is cleared.
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Based on LPA observations and interviews, facility did not have between meals nourishments available for residents. This posed a potential health risk to two of three of residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… this requirement was not met as evidenced by:
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During the visit the leak had been observed as repaired. POC is cleared.
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Based on interviews and observation, the toilet valve was leaking water and was not in good repair. This posed a potential health risk to three of three of residents in care.
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Type B
02/14/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents - To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs… this requirement was not met as evidenced by:
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Facility will be eliminating the call pendants and hire additional staff with increased monitoring. Staff schedule will be provided to LPA by POC due date, 02/14/2023.
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Based on LPA observations, the Licensee did not have residents call pendants turned on. This posed an potential safety risk to two of three of residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 08-AS-20221206114840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING
FACILITY NUMBER: 374604483
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/2023
Section Cited
CCR
87468.2(a)(1)
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87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities - To have a reasonable level of personal privacy in accommodations…this requirement was not met as evidenced by:
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The camera was removed and during the visit there were no cameras in the bedroom.
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Based on LPA observation, the Licensee did not provide resident privacy in accommodations and had a video camera in resident’s bedroom. This posed a potential personal rights to two of three of residents 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: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8