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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604143
Report Date: 12/08/2021
Date Signed: 12/09/2021 09:25:14 AM

Document Has Been Signed on 12/09/2021 09:25 AM - 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:OCEAN HILLS ASSISTED LIVING & MEMORY CAREFACILITY NUMBER:
374604143
ADMINISTRATOR:JOHNSTON, SHERYLFACILITY TYPE:
740
ADDRESS:4500 CANNON RDTELEPHONE:
(760) 295-8515
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 140CENSUS: 102DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Sheryl Johnston, Joan GomezTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit to follow up on an incident report received on December 7, 2021. LPA Ryan introduced herself, stated the purpose of the visit, was allowed entry and met with Executive Director, Sheryl Johnston and Resident Care Director, Joan Gomez.

Community Care Licensing (CCL) received an incident report on December 7, 2021, regarding a resident having a witnessed fall on October 5, 2021.

During today's visit, LPA toured the facility, reviewed resident records, and interviewed staff and residents.

Based on interviews and record review, the licensee did not submit an incident report within seven days of a serious injury of a resident to the licensing agency. A deficiency is being cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on an LIC 809-D.

An exit interview was conducted, and a plan of correction was jointly made with the licensee. A copy of the report, LIC 809-D, and Licensee/Appeal Rights (LIC 9058 01/16) will be emailed to the licensee following the visit. Acknowledgement of receipt of the documents is requested upon receipt
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 12/09/2021 09:25 AM - It Cannot Be Edited


Created By: Kristina Ryan On 12/08/2021 at 12:21 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: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2021
Section Cited
CCR
877211(1)(B)

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87211 Reporting Requirements (1) (B) A written report shall be submitted to the licensing agency…within seven days of the occurrence of…any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by:
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Facility has immediately added another employee to review and submit incident reports. Facility will have a training regarding reporting requirements per Title 22. Training will occur on or before December 29, 2021.Facility will submit training topics and sign in sheet to LPA by December 30, 2021.
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Based on interviews and records review, the licensee did not submit an incident report within seven days of a serious injury of a resident to the licensing agency for 1 out of 102 residents in care, which poses a potential Health risk to residents 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:Simon Jacob
LICENSING EVALUATOR NAME:Kristina Ryan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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