<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236804088
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:49:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231121111127
FACILITY NAME:OCEANSIDE CARE HOME LLCFACILITY NUMBER:
236804088
ADMINISTRATOR:OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:550 S. FRANKLIN STREETTELEPHONE:
(614) 747-3443
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY:5CENSUS: 3DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Annaky BuschTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify authorized representative of residents change in condition
Due to neglect, resident sustained multiple pressure injuries
Due to staff negligence, resident sustained a leg wound infection
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from an investigation into the above allegations. LPA met with Annaky Busch. Based on records reviewed and interviews conducted, Resident, R1, was admitted to this facility 01/12/2023. The service plan on file in the facility was dated 8/28/2023 and marked as an update, but there was no previous plan available. The service plan indicated R1 was a fall risk and staff would be available at all times to supervise movements. Facility conducted a skin assessment evaluation on 01/20/2023, with no future assessments on record. R1 was seen in the emergency room on 10/28/2023 for a laceration to the leg. CCLD did not receive a written report per regulation. Based on hospital records, R1 received sutures to close the laceration and returned to the facility with aftercare instructions. Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 4
Control Number 21-AS-20231121111127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OCEANSIDE CARE HOME LLC
FACILITY NUMBER: 236804088
VISIT DATE: 02/29/2024
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
26
27
28
29
30
31
32
Instructions contained a notice for R1 to return the the ER if there was any increased redness, pain or swelling, and to return in 10 days to have sutures removed. Based on interviews conducted, a previous staff person felt it was the safer for R1 if they were stay in bed while recovering. Facility did not have any documentation whether the wound was cleaned or checked from 10/28/2023 to 11/08/2023. On 11/08/2023, R1 returned to the Hospital for suture removal and was admitted for an infection of the wound. Based on hospital records, R1 was found to have several new pressure injuries since the previous visit on 10/28/2023.
Based on interviews conducted, the staff responsible for resident care during this time frame left employment on 11/29/2023. LPA spoke with Administrator about changes that were made in facility operation to ensure residents are observed for changes and how staff are being trained. Administrator informed LPA they are communicating more frequently with resident care teams and responsible parties to ensure resident needs are being met.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
A copy of this report was left at facility and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231121111127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE CARE HOME LLC
FACILITY NUMBER: 236804088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident:The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is
1
2
3
4
5
6
7
Licensee to ensure staff are trained to observe and report observed changes in the condition of residents. Staff are currently receiving training. POC Cleared at time of visit.
8
9
10
11
12
13
14
provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the medical needs of R1 were met. This poses an Immedate Health risk to residents.
8
9
10
11
12
13
14
Type A
03/01/2024
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate
1
2
3
4
5
6
7
Licensee to ensure resident responsible parties are informed of changes in resident condition and care needs. Facility staff are currently receiving training. POC Cleared at time of visit.
8
9
10
11
12
13
14
to their needs. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, Licensee did not inform responsible party of residents change in condition, which posed an Immediate Health risk to resident.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2023 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20231121111127

FACILITY NAME:OCEANSIDE CARE HOME LLCFACILITY NUMBER:
236804088
ADMINISTRATOR:OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:550 S. FRANKLIN STREETTELEPHONE:
(614) 747-3443
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY:5CENSUS: 3DATE:
02/29/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Annaky BuschTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff over medicated resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from an investigation into the above allegation. LPA met with Annaky Busch. Based on records reviewed and interviews conducted, prior to November 2023, the facility did not utilize a medication administration record, MAR. Staff would assist with resident medications but the only record was the centrally stored medication record. In November 2023, the facility began to use a MAR to keep track of each dose of medication. Facility no longer has any medication for Resident and no accounting of how much was remaining after they left the facility.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4