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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804089
Report Date: 02/28/2025
Date Signed: 02/28/2025 10:40:31 AM

Document Has Been Signed on 02/28/2025 10:40 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OCEANSIDE CARE HOME LLCFACILITY NUMBER:
236804089
ADMINISTRATOR/
DIRECTOR:
OKORO, SYLVESTERFACILITY TYPE:
740
ADDRESS:535 E. CHESTNUT STREETTELEPHONE:
(707) 409-5004
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 6CENSUS: 4DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Valesia ColeTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Valesia Cole and explained the purpose of the visit. Administrator certificate is current.

At approximately 9:00AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Hot water measured within regulation. No pools/bodies of water are on the premises. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen contained cooking/dining equipment that was clean and orderly, utensils were present. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency water supply was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. Facility has been conducting emergency drills every 3 months.

At approximately 9:20AM, LPA conducted a review of medications. Medication is locked and not accessible. First aid kit was present. At approximately 9:35AM, LPA reviewed 4 of 4 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present.

At approximately 9:50AM, LPA reviewed 2 of 2 staff files. 1 of 2 files did not contain evidence of completed initial training. First Aid/CPR certification was current. All employees requiring background checks are cleared.

Continued on LIC809-C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 236804089
VISIT DATE: 02/28/2025
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Evidence of control of Property, (Current Rental/Lease Agreement/Deed)
LIC500- Personnel Report
Evidence of Liability Insurance


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.

This report was reviewed with Valesia Cole and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2025 10:40 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 02/28/2025 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE CARE HOME LLC

FACILITY NUMBER: 236804089

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 2 staff files reviewed. Licensee did not ensure file contained documentation of completed training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee shall ensure all staff receive at least 40 hours of training in the first 4 weeks of employment and at least 20 hours of training every 12 months. LIcensee shall submit self certification of completed training to CCL by 03/28/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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