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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604192
Report Date: 12/29/2022
Date Signed: 12/29/2022 10:56:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/04/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20221004103235
FACILITY NAME:OCEANSIDE REST HOME, INCFACILITY NUMBER:
374604192
ADMINISTRATOR:NAVASAK, SIERAFACILITY TYPE:
740
ADDRESS:4451 SAN JOAQUIN STREETTELEPHONE:
(760) 822-6182
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Siera NavasakTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff grabbed resident's arm causing a bruise
Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation 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 Caregiver Lucita Credito. Licensee Siera Navasak arrived during the visit.

During today's visit, LPA interviewed Licensee and observed residents in care.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, records review, and a tour of the facility. It was alleged that a staff grabbed resident’s arm causing a bruise and staff did not treat resident with dignity. Review of resident 1 (R1) medical records revealed that R1 did not have a memory impairment or diagnosis of dementia, was able to communicate needs, was able to follow directions, and was on a regular bathroom schedule.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 3
Control Number 08-AS-20221004103235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: OCEANSIDE REST HOME, INC
FACILITY NUMBER: 374604192
VISIT DATE: 12/29/2022
NARRATIVE
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Review of R1’s facility records revealed that R1 had a history of agitation during incontinence care and refusing showers. Interviews revealed that in September 2022, R1 had an episode of incontinence and soiled their clothing. Staff 1 (S1) asked R1 to shower but R1 refused. S1 then took R1’s soiled pants and put them near R1’s face to show R1 that they needed to shower and R1 became upset and angry. Interviews revealed that S1 attempted get R1 to shower and R1 started yelling at S1 to “stop it” in response to being told to get in the shower. S1 was able to get R1 into the shower and began showering R1. Interviews revealed that while S1 showered R1, S1 grabbed R1’s left arm. R1 was observed with bruising in that area and reported pain after being grabbed. Interviews and record review revealed that on October 4, 2022, S1 indicated that R1 raised their arm to block S1 from spraying water on R1 and the shower-head cord wrapped around R1’s arm which caused R1’s bruising in that area. Interviews revealed that S1 was rude to residents and would yell and curse at residents when S1 was frustrated. Interviews revealed that the residents did not like the care provided by S1. The Department was unable to interview S1 due to S1 being unavailable.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Licensee Siera Navasak, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 08-AS-20221004103235
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME, INC
FACILITY NUMBER: 374604192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) residents... shall have all of the following personal rights (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement has not been met as evidenced by:
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Immediate risk has been removed, LPA verified with the Licensee that S1 is no longer working at the facility as of 10/5/2022.
Licensee will conduct an in-service training on reporting requirements, personal rights, and abuse training for staff and provide sign in sheets to the Department by POC due date.
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Based on interviews and records review, the Licensee did not ensure R1 was free from abuse resulting in bruising. This poses an immediate personal rights risk to 6 of 6 residents in care.
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Type B
01/20/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) residents... shall have all of the following personal rights (2) to be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by:
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Licensee will conduct an in-service training on reporting requirements, personal rights, and abuse training for staff and provide sign in sheets to the Department by POC due date.
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Based on interviews and records review, the Licensee did not ensure that residents were accorded dignity in their relationship with S1. This poses a potential personal rights risk to 6 of 6 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
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