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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603842
Report Date: 10/11/2024
Date Signed: 10/21/2024 01:16:33 PM

Document Has Been Signed on 10/21/2024 01:16 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:OCEANSIDE ELDERLY CARE HOME 452FACILITY NUMBER:
374603842
ADMINISTRATOR/
DIRECTOR:		ALVI, MUHAMMEDFACILITY TYPE:
740
ADDRESS:452 FOUSSAT RDTELEPHONE:
(760) 529-9257
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 6CENSUS: 6DATE:
10/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Caregiver Christopher Diaz and Licensee Dr. Mohammed RahmanTIME VISIT/
INSPECTION COMPLETED:
09:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. 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 Rahan during the visit.

Interviews of facility staff showed that that when residents were short 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. The supplies in question were paid for by those residents or their RPs, and not by the Licensee. Interviews identified at least two affected residents, Resident #2 (R2) and Resident #5 (R5).

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 809-D, 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
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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Document Has Been Signed on 10/21/2024 01:16 PM - It Cannot Be Edited


Created By: Dang Nguyen On 10/11/2024 at 06:51 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 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
87468.1(a)(12)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12)…to keep and use their own personal possessions, including their toilet articles…” 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 uphold the right of 2 of 6 residents (R2 and R5) to keep and use their own personal possessions, including their toilet articles. 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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