374603237-8-8-2025-08-AS-APAO-DKJ8LY-20250813223730

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603237
Report Date: 08/08/2025
Date Signed: 08/08/2025 10:45:45 AM

Unsubstantiated

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
05/05/2025 and conducted by Evaluator Rebecca A Borunda

COMPLAINT CONTROL NUMBER: 08-AS-20250505090137

FACILITY NAME:	ROXIES ELDERLY HOMES II		FACILITY NUMBER:	374603237
ADMINISTRATOR:	TERESITA ROXAS		FACILITY TYPE:	740
ADDRESS:	4560 VINYARD STREET		TELEPHONE:	(442) 266-2939
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	08/08/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Administrator Teresita "Roxie" Roxas		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff did not initiate medical assistance to resident timely
Facility staff did not accord resident with dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Ofelia Fortunato. Administrator Teresita "Roxie" Roxas arrived during the visit.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not initiate medical assistance to Resident 1 (R1) in a timely manner and staff did not accord resident with dignity. Interviews with staff and outside sources revealed that sometime around 5:30pm on 4/26/2025, R1 began bleeding from a port on their arm. R1 provided conflicting information regarding the timing of the event and stated that the bleeding occurred in the early morning, however, the exact time could not be verified. Residents and staff stated that residents ring a bell to notify staff when residents need assistance.
Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250505090137

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: ROXIES ELDERLY HOMES II	FACILITY NUMBER: 374603237
	VISIT DATE: 08/08/2025

NARRATIVE

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Interviews revealed that R1 used a bell to alert staff that R1 needed assistance, however staff did not immediately respond to the bell, prompting R1 to ring the bell again and yell that they needed help. Staff 1 (S1) estimated that it was about a minute between R1’s first bell call and when S1 responded to R1’s room. Interviews revealed that S1 responded to R1’s room and made a comment stating that R1 was not the only resident requiring assistance and S1 could not immediately respond to R1’s calls. Interviews with staff revealed that two other staff were present at the facility who were not actively on shift during the incident. Interviews with staff revealed that once S1 observed that R1 was bleeding, S1 grabbed a towel to cover R1’s port to stop the bleeding and called 911. Interviews with S1 revealed that while S1 was on the phone with emergency services, one of the off-duty staff called the Administrator, which the Administrator confirmed during interviews. R1 was transported to the hospital via emergency services and returned to the facility on 4/29/2025. The Administrator stated that R1 was transported to the hospital within 15 minutes of S1 calling 911, however, other staff and residents were unable to provide a clear timeline of events between R1 beginning to bleed and when R1 was transported to the hospital. Interviews with staff and residents and medical discharge paperwork revealed that on 5/3/2025, R1’s port began bleeding again. Staff stated that S1 placed a towel on R1’s arm to stop the bleeding. Interviews with staff as well as review of S1’s personal cell phone call log revealed that S1 called 911 on 5/3/2025 at 9:43pm and the call lasted approximately 3 minutes. S1 stated that they stayed on the phone with 911 until emergency personnel arrived at the facility. Review of photographs provided to the Department by S1 revealed that emergency personnel were present at the facility at 9:57pm and medical paperwork revealed that R1 was admitted to the hospital at 10:38pm. Interviews did not provide the Department with a clear timeline of how long emergency services were present at the facility before transporting R1 to the hospital. Interviews with residents did not reveal concerns that staff were rude or spoke to residents inappropriately. Interviews with staff as well as review of progress notes revealed that R1 could be demanding and engaged in yelling and cursing behaviors. Staff also stated that R1 wanted assistance and requests for items or care answered immediately.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Administrator Teresita "Roxie" Roxas, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC9099 (FAS) - (06/04)

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