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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804186
Report Date: 11/01/2024
Date Signed: 11/01/2024 11:28:36 AM

Document Has Been Signed on 11/01/2024 11:28 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 RETIREMENT LIVINGFACILITY NUMBER:
236804186
ADMINISTRATOR/
DIRECTOR:		GYURICS, TUNDEFACILITY TYPE:
740
ADDRESS:100 S HAROLD STREETTELEPHONE:
(916) 616-7020
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 3DATE:
11/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kathy KabaiTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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At approximately 9:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a complaint investigation. LPA met with Administrator Kathy Kabai. During this visit, LPA spoke with Administrator about the facilities lack of Liability insurance. Kathy told LPA they are working on securing the required insurance. LPA provided copy of the Health and Safety code regarding Liability insurance. Administrator will send evidence of liability insurance to CCL when received.

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 Kathy Kabai and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 11/01/2024 11:28 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 11/01/2024 at 10:22 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 RETIREMENT LIVING
FACILITY NUMBER: 236804186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
HSC
1569.605

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1569.605 Liability insurance; coverage requirements:On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three
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Licensee to secure Liability insurance in the amounts required by law. Licensee to submit evidence of Liability insurance to CCL by POC date of 11/15/2024.
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million dollars ($3,000,000) in the total annual aggregate. This requirement is not met as evidenced by: Based on records reviewed, Licensee does not have Liability insurance, which poses a potential risk to 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:Bethany Moellers
LICENSING EVALUATOR NAME:Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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