374603496-9-26-2023-08-AS-SJAB-CW4MPJ-20230928094712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603496
Report Date: 09/26/2023
Date Signed: 09/26/2023 06:02:36 PM

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
02/23/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230223124259

FACILITY NAME:	PACIFIC BREEZE		FACILITY NUMBER:	374603496
ADMINISTRATOR:	PHOMTHAVONG, KEVIN		FACILITY TYPE:	740
ADDRESS:	137 PLAYA DEL REY AVE		TELEPHONE:	(760) 453-2722
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92058
CAPACITY:	6	CENSUS: 6	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Monica Siharath Licensee		TIME COMPLETED:	12:23 PM

ALLEGATION(S):

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Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted a complaint investigation visit to deliver findings for the above allegation. LPA Domingo met with Monica Siharath, Licensee and shared the findings.

The Department’s investigation consisted of record reviews, interviews with staff, and outside sources.

It was alleged the facility unlawfully evicted a resident. Outside Source 1 (OS1) was interviewed and stated that Resident 1 (R1) was not evicted and returned to the facility. LPA Domingo reviewed records that verified that R1 was not evicted from the facility. Outside Source 2 (OS2) was interviewed and R1 was not evicted from the facility.

[Continued on LIC9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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-20230223124259

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: PACIFIC BREEZE	FACILITY NUMBER: 374603496
	VISIT DATE: 09/26/2023

NARRATIVE

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[Continued from LIC9099]

Staff 1 (S1) was interviewed and verified that R1 was scheduled to return to the facility. R1's records reviewed collaborated with S1 and OS1, that R1 was scheduled to return to the facility. LPA Domingo reviewed the facility Admission Agreement and facility policy/guidelines on providing care for residents and R1's records showed that R1 was able to return and the facility was accepting R1's return.

The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegations are determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Monica Siharath, Licensee and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provide.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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