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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603841
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:02:34 PM

Document Has Been Signed on 06/19/2024 03:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 448FACILITY NUMBER:
374603841
ADMINISTRATOR/
DIRECTOR:		ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:448 FOUSSAT RDTELEPHONE:
(760) 807-8585
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 6CENSUS: 2DATE:
06/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Administrator Muhammed AlviTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Arnel Reclusado. Administrator Muhammed Alvi arrived during the visit.

The facility is licensed for a maximum capacity of 6 non-ambulatory residents, 3 of which may be bedridden. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 2 non-ambulatory residents. The Administrator for the facility is Muhammed Alvi and their certificate was valid and current.

During visits on 5/31/2024 and 6/19/2024, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 141.5 degrees Fahrenheit in a common bathroom and 143.2 degrees Fahrenheit in a shared resident bathroom. Facility staff adjusted the water heater during the visit. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Muhammed Alvi, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs.

Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841
VISIT DATE: 06/19/2024
NARRATIVE
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Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Muhammed Alvi, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2024 03:02 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 06/19/2024 at 02:14 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water was measured at 141.5 and 143.2 degrees F in bathrooms for resident use which poses an immediate safety risk to 2 of 2 residents in care.
POC Due Date: 07/01/2024
Plan of Correction
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Facility staff adjusted the hot water temperature during the visit. Facility staff will conduct checks of water temperature in bathrooms every other day for a week in a written log. Administrator will submit copy of the log to the Department by POC due date of 7/1/2024.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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