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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604143
Report Date: 12/13/2024
Date Signed: 12/13/2024 12:05:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/01/2021 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20210601095347
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: 110DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Executive Director Sheryl JohnstonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Licensee did not comply with terms and conditions of the admission agreement
Residents are not being adequately assessed for the appropriate level of care
Licensee is not updating appraisal to accurately reflect the residents service needs
Insufficient staff to meet residents care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston. During today's visit, LPA observed residents in care and reviewed and obtained copies of facility records.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that the licensee did not comply with terms and conditions of the admission agreement, specific to meal quality, residents were not assessed for appropriate level of care,
the licensee did not update appraisal to reflect residents’ service needs, and insufficient staff to meet resident care needs. Review of resident assessment records, needs and service plans, and physician’s reports from residents present at the facility in 2020 revealed that several residents had multiple care assessments and needs and services plans that were updated as changes in condition were observed.
Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
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 5
Control Number 08-AS-20210601095347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 12/13/2024
NARRATIVE
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Review of Resident 1’s (R1's) documents revealed that R1 was had two assessments conducted in September 2020 and an additional care assessment in November 2020 due to increasing care needs. In September 2020, R1’s care needs included standby assistance for bathing, reminders for meals, and noted that R1 was a fall concern. During the November 2020 assessment, R1’s care needs increased to require full assistance from staff for all activities of daily living due to a fall. R1 was also placed on the facility’s waitlist for memory care, and communications between R1’s responsible party and physician dated October 2020 agreed that it was in R1’s best interest to be placed on the waitlist instead of relocating to a different facility. Additionally, R1’s responsible party had arranged for R1 to have a third party caregiver provide 1 on 1 supervision, which interviews with outside sources confirmed. R1 also began receiving hospice services sometime between November and December 2020. Review of fax communications revealed that R1’s physician and responsible party were kept informed of and were in agreement with R1’s increasing care needs. Interviews with outside sources revealed that there were some concerns regarding supervision, however, the concern was with the third party agency that was hired by R1’s responsible party and outside sources denied concerns with the facility staff's ability to meet R1's increasing care needs.

Review of Resident 2’s (R2's) assessment records for October 2020 revealed that R2 required reminders for meals and dressing and required 1 person assistance for bathing. Review of R2’s physician report for December 2020 revealed that R2 had a diagnosis of major cognitive impairment, was confused and disoriented, had auditory and visual impairment and was occasionally incontinent. R2 was reassessed in January 2021 and review of R2’s physician report and needs and services plan from January 2021 revealed that R2 began receiving hospice services, required reminders for meals and toileting, required 1 person assistance for bathing and was at risk for falls. Review of fax communications between the facility and R2’s physician revealed that the facility maintained communication regarding R2’s changes in condition including falls.

Review of Resident 3’s (R3's) physician’s report from August 2019 revealed that R3 had a diagnosis of mild cognitive impairment, was not confused or disoriented, was able to follow directions and communicate needs and was able to manage their medications independently. Review of fax communications revealed that beginning in September 2020, R3 was observed to have increasing confusion and agitation. Review of R3’s needs and service plans dated April 2021 revealed that while R3 did not have any increasing care needs, R3 required reassurance from staff to prevent agitation and distrust of staff. Review of assessment documents for R1, R2, and R3 did not reveal evidence that supported the allegation that residents were not appropriately assessed or that resident's appraisals were not updated to meet resident's care needs.
Continued on LIC9099-C page...
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20210601095347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 12/13/2024
NARRATIVE
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Review of the staff schedule for November 2020 revealed that the facility scheduled between 4 and 5 care staff including medication technicians per shift and scheduled between 2 and 3 care staff including medication technicians scheduled for the overnight shift. Interviews with residents did not reveal evidence that staff were not able to meet resident care needs and residents stated that staff were very attentive and helpful. Evidence obtained during interviews with outside sources corroborated that staffing level was sufficient to meet resident care needs. Interviews with staff were inconsistent regarding the ability of staff to meet the care needs of residents. Staff interviews provided conflicting information, with some interviews stating that the staff level during shifts matched the November 2020 staff level and other interviews revealed that there were multiple instances where there were approximately 3 caregivers during a shift, with one caregiver per floor in assisted living and one caregiver in the facility’s memory section.

Review of the admission agreement used by the facility in 2019 and 2020 revealed that the facility agreed to provide residents with meals three times a day and in-between meal snacks. The admission agreement stated that meals would be provided "restaurant-style" in the facility's dining room or via tray service due to temporary sickness or at an additional fee. Additionally, the facility offered catering services to a resident's apartment or to a common area with prior notice and at an additional fee. Interviews with staff and residents did not reveal any concerns regarding the food quality, variety of options, or the facility’s ability to accommodate special diets. Review of the admission agreement revealed that the facility did not promise to provide a certain quality or level of dining experience to residents beyond providing meals in a restaurant like setting.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
06/01/2021 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20210601095347

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: 110DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Executive Director Sheryl JohnstonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
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9
Licensee is not following appropriate fire clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Sheryl Johnston. During today's visit, LPA observed residents in care and reviewed and obtained copies of facility records.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review, and a tour of the facility. It was alleged that the licensee was not following appropriate fire clearance, specific to residents with a diagnosis of major cognitive impairment were residing in the facility’s assisted living portion of the building. Review of regulations specific to admission and retention of residents revealed that residents with a diagnosis of major cognitive impairment were not required to be relocated to a delayed egress or locked unit.

Continued on LIC9099-C page…
Unfounded
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20210601095347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEAN HILLS ASSISTED LIVING & MEMORY CARE
FACILITY NUMBER: 374604143
VISIT DATE: 12/13/2024
NARRATIVE
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Review of a random sampling of residents’ assessment records, needs and services plans, and additional care assessment documents did not reveal residents who had wandering or exit seeking behavior that could not be managed by staff redirection. Review of incident reports submitted to the Department by the facility and review of licensing reports between September 2020 and December 2021 did not reveal any instances of resident elopements or wandering that resulted in injury.

The Department has investigated the above-mentioned allegation and based on record review, this allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Executive Director Sheryl Johnston, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5