374604483-4-18-2024-08-AS-RARZ-D4FVJ5-20240418162811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604483
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:28:18 PM

Document Has Been Signed on 04/18/2024 04:28 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:	SHORESIDE VILLA ASSISTED LIVING		FACILITY NUMBER:	374604483
ADMINISTRATOR:	KAHNIS, KEVIN		FACILITY TYPE:	740
ADDRESS:	1911 S FREEMAN ST		TELEPHONE:	(442) 266-2107
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92054
CAPACITY:	3	CENSUS: 3	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Caregiver Mina Radjabi		TIME COMPLETED:	04:30 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 Analysts (LPAs) Rebecca Ruiz and Ryan Fulton conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Caregiver Mina Radjabi. LPAs spoke with Administrator Quetzalli "Sally" Kahnis via telephone during the visit. The facility is licensed for a maximum capacity of 3 ambulatory residents. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 3 residents, 2 of which were non-ambulatory. LPAs did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Quetzalli "Sally" Kahnis and their certificate was valid and current. During today’s visit, LPAs toured the facility and inspected each room of the facility, including resident rooms, bathroom for resident and staff use, kitchen, common areas, and outside space. No bodies of water were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 105.1 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPAs observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Sally K, no firearms or weapons are stored on the premises. LPAs also observed knives stored in an unlocked kitchen cabinet and resident medications were stored in an unlocked filing cabinet. Resident medications are stored in their original container and label. LPAs observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPAs observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page…

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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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Document Has Been Signed on 04/18/2024 04:28 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 374604483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(1)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review, the licensee did not comply with the section cited above in 2 of 3 residents are who non-ambulatory without a non-ambulatory fire clearance, which poses an immediate safety risk to 3 of 3 residents in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator will submit LIC200 and facilty sketch requesting non-ambulatory clearance to the Department by POC due date of 4/19/2024.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that knives were stored in an unlocked kitchen cabinet. This poses an immediate safety risk to 3 of 3 residents in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	LPAs observed staff secured knives in a locked cabinet during the visit.

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: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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: SHORESIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 374604483
	VISIT DATE: 04/18/2024

NARRATIVE

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LPAs reviewed multiple resident and staff records. LPAs spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiencies for fire clearance, unlocked medications, and unlocked knives were cited and noted on the attached LIC809-D pages. Additionally, a civil penalty for a total of $500 is being cited for fire clearance and noted on the attached LIC421IM.

LPAs were away from the facility for approximately 1 hour between 12:00pm and 1:00pm.

An exit interview was conducted with Administrator Quetzalli "Sally" Kahnis via telephone and Caregiver Mina Radjabi, whose signature below confirms receipt of a copy of this report, LIC811, LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2024 04:28 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SHORESIDE VILLA ASSISTED LIVING	FACILITY NUMBER: 374604483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that 3 of 3 residents medications were stored in an unlocked filing cabinet which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	LPAs observed the medications were locked and key was removed from filing cabinet during the visit. Administrator will conduct training on storing dangerous items and will provide proof of completion to the Department by POC due date of 4/30/24.

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.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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