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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604143
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:16:24 PM

Document Has Been Signed on 11/09/2023 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: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: 119DATE:
11/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Executive Director Sheryl JohnstonTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with 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 (received on 10/04/2023), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a facility tour / welfare check, collected copies of pertinent records, and interviewed R1 and relevant staff.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Johnston, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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