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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603842
Report Date: 10/11/2024
Date Signed: 10/11/2024 08:54:30 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
10/11/2024 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20241011114303
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 452FACILITY NUMBER:
374603842
ADMINISTRATOR:ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:452 FOUSSAT RDTELEPHONE:
(760) 529-9257
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:6CENSUS: 6DATE:
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 assist resident with teeth brushing.
-Licensee did not ensure resident had hygiene supplies.
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 Licensee’s staff did not assist Resident #1 (R1) with teeth brushing, and that Licensee’s staff did not ensure that R1 had hygiene supplies. [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check to observe resident’s mouths / oral hygiene. The Department also interviewed pertinent facility staff and outside sources and reviewed relevant care records. LPA attempted to interview R1 and each of their housemates, 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]
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 3
Control Number 08-AS-20241011114303
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 452
FACILITY NUMBER: 374603842
VISIT DATE: 10/11/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

In their interview, Staff #1 (S1) admitted to LPA that from around 09-10-2024 through 10-03-2024, they and their fellow caregivers were not brushing R1’s teeth (they were using mouthwash only). S1 also admitted to LPA that during this same period, R1 did not have a toothbrush or toothpaste at the facility, and that by 10-03-2024, R1 had also just run out of body wash. (There is no evidence at this time that R1’s missed any showers during the review period.)

Staff interviews unanimously showed: R1’s responsible person (RP) had primary responsibility for refilling R1’s toiletry supplies as needed, and that RP was responsive/timely with this task when alerted by facility staff. However, interviews showed that during the complaint allegation time frame, facility staff did not notify the RP that R1 needed refills on toiletry supplies. (RP was since notified and brought in refills on the required items). Interview of multiple facilty staff further showed that that when residents ran low on personal supplies in the past, staff sometimes took supplies belonging to one resident to use/share for another resident, instead of alerting the appropriate responsible persons (RP) and/or facility management.

During today’s inspection, LPA briefly inspected 6 of 6 resident’s mouths (with those residents’ permission), finding no evidence of bad breath or excessive tartar or food build up, at present. While Licensee maintained reserve incontinence supplies in the facility’s garage, LPA observation and staff interviews showed Licensee did not maintain toiletry supplies (such as shampoo, soap/body wash, toothpaste, toothbrushes) at the facility, as part of a reserve inventory, for instances when RPs might be delayed with resupply.

Based on records and interviews, a preponderance of evidence exists to show that Licensee’s staff did not assist R1 with teeth brushing, and that Licensee’s staff did not, at all times, ensure that R1 had hygiene supplies. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). 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 page, the LIC811 Confidential Names List, 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: 2 of 3
Control Number 08-AS-20241011114303
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 452
FACILITY NUMBER: 374603842
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
87101(c)(3)
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87101 Definitions: “(c)(3) ‘Care and Supervision’ shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene…” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, interviews show facility staff had resumed brushing R1’s teeth. This resolves the immediate risk. Licensee agreed to retrain all staff on expectations around ADL care provided to residents and around the resupply of items/supplies needed to perform ADL tasks. Licensee agreed to E-mail the training sign-in sheet to LPA, by 11-11-2024.
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Based on interviews, Licensee did not meet the grooming/hygiene needs of 1 of 6 residents (R1). This posed a potential health and personal rights risk to persons in care.
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Type B
11/11/2024
Section Cited
CCR
87307(a)(3)
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87307 Personal Accommodations and Services: “(a) The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.” This requirement was not met, as evidenced by:
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Licensee agreed to build and maintain a reserve inventory at the facility of at least the following items: Toothbrushes, toothpaste, mouthwash, shampoo, and soap/body wash. Licensee agreed to retrain all caregivers on expectations around ADL care provided to residents and around the resupply of items/supplies needed to perform ADL tasks. Licensee agreed to E-mail the training sign-in sheet and a photograph of the reserve inventory of toiletries, to LPA, by the POC due date.
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Based on interviews, Licensee did not ensure that 1 of 6 residents (R1) had supplies necessary for personal care and maintenance of adequate hygiene practice readily available to them. This posed a potential health and personal rights risks 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: 3 of 3