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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603841
Report Date: 10/11/2024
Date Signed: 10/11/2024 08:34:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240821121132
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 448FACILITY NUMBER:
374603841
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:448 FOUSSAT RDTELEPHONE:
(760) 807-8585
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 0DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Caregiver Christopher Diaz and Licensee Dr. Mohammed RahmanTIME COMPLETED:
09:00 PM
ALLEGATION(S):
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-Licensee did not notify physician of resident’s skin tear.
-Licensee did not meet other reporting requirements.
-Licensee involuntary transferred a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit.

The Complainant alleged that after Resident #1 (R1) sustained a skin tear on their lower left leg, Licensee did not notify R1’s doctor, as required. They also alleged that Licensee also did not notify R1’s responsible person (RP) and CCLD, as required. They also alleged that Licensee involuntary moved R1 and Resident #2 (R2) out of the facility. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tour/welfare check and interviews of pertinent staff and outside sources. The Department also reviewed relevant care records. LPA attempted to interview R1 and R2 about the above allegations, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. [CONTINUED ON LIC 9099-C, 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 08-AS-20240821121132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Care records and interviews aligned to show that R1 was memory-impaired, wheelchair-bound, took blood-thinner medication, had very fragile skin, had a history of being prone to bruising and skin tears, and required staff assistance with bathing, among other tasks. Interviews of multiple staff and outside sources corroborated that during mid-July 2024, R1 sustained a skin tear on their lower left leg. CCLD obtained a photograph of the skin tear, showing that at one point, the open area of skin was around 3 inches long by 2 inches wide.

In their interview, Staff #1 (S1) confirmed that while cleaning R1’s lower left leg with a loofah during a shower, they scrubbed too hard and accidentally caused the skin tear. S1 admitted that they did not inform either R1’s NP or PCP, or facility management. S1 also admitted they did not inform the RP until eight (8) days after it had occurred, and only after the RP had visited the facility and confronted S1 with questions about the skin tear. Interviews of the PCP and NP confirmed that facility staff did not notify them of R1’s injury. Interviews of Staff #2, Staff #3, and outside sources confirmed S1’s account, and that Licensee’s staff did not notify RP of the injury until over a week later. LPA reviewed the CCLD San Diego Regional Office’s files, finding that Licensee did not submit a written incident report regarding R1 sustaining a skin tear on their lower left leg (which was required to be done within seven days of incident occurrence). By the start of CCLD’s investigation, the skin in the affected had already scabbed over and healed, yet 2 of 2 facility Licensees/managers and 2 of 5 caregivers (who directly cared for R1) interviewed were still unaware of said earlier skin tear on R1’s leg. There was also no written documentation of this skin tear on R1’s lower left leg in the facility’s records, as was required.

Interviews of facility Licensees/managers, caregivers, and outside sources aligned to show: During the time frame of the complaint, R1 and R2 were the only two residents in care at Oceanside Elderly Care Home 448. On a day in late July 2024, Licensee moved R1 and R2 to new bedrooms at Oceanside Elderly Care Home 452 (a separate CCLD-licensed care facility), to consolidate operations and reduce operating costs. Licensee did not prior notify CCLD of these transfers, or the fact that Oceanside Elderly Care Home 448 would become dormant. [CONTINUED ON LIC 9099-C, 2 of 2]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20240821121132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099-C, 1 of 2]

R1 and R2, per their latest physician’s reports and care records, both suffered from memory loss. LPA interviewed each and found neither could provide informed consent to transferring facilities. Manager and outside source interviews further showed that Licensee did not notify R1’s responsible person about R1’s moving, either before, during, or after the transfer. R1’s responsible person did not consent to the transfer. Per manager interviews, Licensee did contact and receive permission from R2’s responsible person to transfer R2. LPA attempted multiple times to interview R2’s responsible person to confirm this but was unsuccessful in reaching them.

Based on records and interviews, a preponderance of evidence exists to show: After R1 sustained a skin tear on their lower left leg, Licensee did not notify R1’s healthcare providers of the injury, Licensee did not meet other reporting requirements, and Licensee involuntary transferred R1. These three (3) allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). Plans of Correction were jointly developed with the Licensee.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 9099-D pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20240821121132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87466
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87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident’s physician and the resident’s responsible person, if any.” This requirement was not met, as evidenced by:
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Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.
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Based on records and interviews, 1 of 2 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.
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Type B
11/11/2024
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident."
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Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, 1 of 2 residents (R1) had an incident which threatened their welfare/health, and Licensee did not submit a written report of the incident to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20240821121132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2024
Section Cited
CCR
87468.2(a)(20)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions…‘involuntary’ means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.”
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As of the date of deficiency issuance, the responsible person (RP) for R1 has agreed with Licensee’s decision to keep R1 in their current bedroom at Oceanside Elderly Care Home 452, for the time being. Licensee agreed that if at a future point they desire for R1 to move back to Oceanside Elderly Care Home 448, they will first communicate with R1’s RP, receive their consent, and meet all regulatory requirements.
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This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 2 residents (R1) was protected from involuntary transfer. The transfer was initiated by the licensee, not by the resident. This posed a potential personal rights risk to persons 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20240821121132

FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 448FACILITY NUMBER:
374603841
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:448 FOUSSAT RDTELEPHONE:
(760) 807-8585
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 0DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Caregiver Christopher Diaz and Licensee Dr. Mohammed RahmanTIME COMPLETED:
09:00 PM
ALLEGATION(S):
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Licensee did not meet background clearance requirements for staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit.

The Complainant alleged that Licensee did not ensure that Staff #4 and Staff #5, who worked as caregivers at the facility amongst residents, had the necessary background / criminal-record clearances with CCLD. CCLD’s investigation involved reviewing the facility’s employee roster against the Department’s background-clearance databases. LPA also conducted unannounced facility tours to interview facility Licensees and caregivers.

[CONTINUED ON LIC 9099-C]
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20240821121132
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEANSIDE ELDERLY CARE HOME 448
FACILITY NUMBER: 374603841
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

Per review of CCLD’s Guardian and Licensing Information System (LIS) databases, during the time frame of the complaint allegation, both S4 and S5, as well as all other current facility staff, were each fingerprinted and possessed active background clearances to work. Interviews of Licensees/managers and facility staff reiterated the same.

Based on record review and interviews, the allegation that Licensee’s staff did not have current background / criminal-record clearances is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was issued for it.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7