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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604143
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:53:08 PM

Document Has Been Signed on 04/11/2023 04:53 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: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: 123CENSUS: 107DATE:
04/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:09 PM
MET WITH:Resident Services Director Dennis Prejusa and Executive Director Sheryl JohnstonTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Director Dennis Prejusa and Executive Director Sheryl Johnston.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 01/09/2023. According to the SOC341: on 01-01-2023, Staff #1 (S1) yelled at and pointed disrespectfully at Resident #1 (R1), as witnessed by Staff #2 (S2). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. There was no physical interaction or injury involved. On 01-02-2023, facility management placed S1 on administrative leave, pending further internal investigation.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, who was indeed unharmed/uninjured. LPA also reviewed pertinent records and interviewed relevant staff.

According to R1’s LIC602 Physician’s Report (dated 12-13-2022): they were not diagnosed with either Dementia or Mild Cognitive Impairment. They had “periods of confusion,” but they were otherwise “able to communicate needs” and had good hearing and vision. According to R1’s LIC603 Preplacement Appraisal (dated 12-12-2022): there was no mention of cognitive impairment, but it was written R1 had a “hard time walking, bathing.” Per the “Psychosocial” section of the Resident Assessment / Care Plan (dated 12-13-2022) which licensee prepared on R1: they were sometimes “forgetful,” but also “Independent” and “alert and oriented X3.” Licensee wrote that R1 used a walker, required “1 person total assist” with ambulation, and instructed their own staff “to walk the resident to and from the dining room.”

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 04/11/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

During their interview with LPA: R1 recalled that S1 yelled at them when they asked for assistance with walking, saying S1 insisted R1 could walk independently and “called me a liar four times.” R1 said the experience felt “awful.” They confirmed there was no physical component to the interaction with S1. Per interview of facility management: S2 saw R1 cry during the incident, and was a credible witness to S1’s actions.

Records revealed that based on its own internal investigation, licensee formally disciplined S1 on 01-10-2023. On 01-27-2023, licensee retrained its larger staff team on topics including Resident’s Personal Rights and Mandated Abuse Reporting. R1 confirmed to CCLD that they have not had problems with S1 before, or since, the 01-01-2023 incident. R1 also confirmed that to date, they have not been treated unkindly by any other facility staff.

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

An exit interview was conducted with Prejusa and Johnston, to whom a copy of this report, the LIC 809-D, 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: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2023 04:53 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/11/2023 at 04:26 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
CCR
87468.1(a)(1)

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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: (1) To be accorded dignity in their personal relationships with staff...”
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Per interviews and record review: Licensee formally disciplined S1 on 01-10-2023 regarding the incident. On 01-27-2023, licensee retrained its larger staff team on Resident’s Personal Rights and Mandated Abuse Reporting. These actions resolve the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff (S1) did not treat 1 of 107 residents (R1) with dignity, which posed an immediate 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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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