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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604533
Report Date: 03/07/2023
Date Signed: 03/07/2023 04:43:23 PM


Document Has Been Signed on 03/07/2023 04:43 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SANTIANNA OAKMONT SIGNATURE LIVINGFACILITY NUMBER:
374604533
ADMINISTRATOR:THARP, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:2560 FARADAY AVETELEPHONE:
(442) 325-8090
CITY:CARLSBADSTATE: CAZIP CODE:
92010
CAPACITY:226CENSUS: 150DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH: Executive Director Sam El-RabaaTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted a complaint investigation visit where an unrelated deficiency was discovered. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Sam El-Rabaa.

During today's visit, LPA conducted interviews and records review, which revealed that an incident report was not submitted to the Department regarding an incident that occurred in February 2023, involving Resident 1 (R1) resulting in no injuries where 911 was contacted to assess R1's condition. Per California Code of Regulations Title 22, the following deficiency is cited on the attached LIC809-D page.

An exit interview was conducted with Executive Director Sam El-Rabaa, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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 03/07/2023 04:43 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: SANTIANNA OAKMONT SIGNATURE LIVING
FACILITY NUMBER: 374604533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2023
Section Cited

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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement has not been met as evidenced by:
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Executive Director stated that he will review regulations regarding reporting requirements and submit an incident report regarding this incident to the Department by POC due date.
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Based on interviews and records review, the Licensee did not submit an incident report to the Department regarding the medication error for R1. This poses an potential safety risk to 150 of 150 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
LIC809 (FAS) - (06/04)
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