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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604587
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:24:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
01/08/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240108170508
FACILITY NAME:OASIS VILLAGE CARE #2FACILITY NUMBER:
374604587
ADMINISTRATOR:SAHID, RAMLAFACILITY TYPE:
735
ADDRESS:12712 ROBISON BLVD.TELEPHONE:
(619) 727-7335
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:4CENSUS: 3DATE:
01/17/2024
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Caregiver Nimo HassanTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility staff did not document administration of medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced visit to initiate a complaint investigation. The LPA identified himself and disclosed the purpose of the visit to Caregiver Nimo Hassan.

During the visit, the LPA conducted a tour of the facility, reviewed pertinent records, and conducted interviews.

It was alleged staff did not document administration of each medication. Review of documents along with staff interviews confirmed staff had not documented each dose, time, nor quantity given at each time. Instead, the facility had documented the total amount of medication, or tablets a client had been assisted with throughout a particular day, and qantity per hour.
Based on evidence obtained, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Administrator Ramla Sahid, over the phone .
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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 3
Control Number 08-AS-20240108170508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OASIS VILLAGE CARE #2
FACILITY NUMBER: 374604587
VISIT DATE: 01/17/2024
NARRATIVE
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An exit interview was conducted with Caregiver Nimo Hassan, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240108170508
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: OASIS VILLAGE CARE #2
FACILITY NUMBER: 374604587
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
80075(b)(6)(C)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.This requirement as not met as evidenced by:
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Administrator agreed to update the facility's medication log, to include time, and additional questions which will note the client's response to each medication taken. Administrator agreed to submit proof of the upated log by 2/2/24.
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Based on a review of records and interviews, the Licensee did not ensure a client's medication log included time of administration of each medication, which posed a potential health, safety and personal rights risk to 3 of 3 clients 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) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3