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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604533
Report Date: 05/24/2024
Date Signed: 05/24/2024 01:43:29 PM


Document Has Been Signed on 05/24/2024 01:43 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:SANTIANNA OAKMONT SIGNATURE LIVINGFACILITY NUMBER:
374604533
ADMINISTRATOR:EL RABAA, SAMFACILITY TYPE:
740
ADDRESS:2560 FARADAY AVETELEPHONE:
(442) 325-8090
CITY:CARLSBADSTATE: CAZIP CODE:
92010
CAPACITY:226CENSUS: 162DATE:
05/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Sam El RabaaTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Sam El Rabaa, to discuss the purpose of the visit. 

Today's visit is in response to the self reported incident of Resident 1 (R1) who suffered a medication error (See LIC811 Confidential Names List).

LPA interviewed staff and residents and collected records and a wellness check was completed. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D).  A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Executive Director Sam El Rabaa, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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 05/24/2024 01:43 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: SANTIANNA OAKMONT SIGNATURE LIVING
FACILITY NUMBER: 374604533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
CCR
87465(c)(2)

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87465(c)(2)- Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, as evidenced by:
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Staff member (S1) was permanently removed from the medication cart on 3/29/24, and was given a corrective action write-up on 4/4/24. This action resolved the potential risk.
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Based on records and interviews, Licensee’s staff did not give 1 of 162 residents (R1) medication according to the physician's direction. This posed a potential health risk to person(s) in care.
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All medication technicians were re-trained and the in-service training paperwork will be submitted to LPA by 5/29/24.

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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: Jennifer LottTELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Nacole PattersonTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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