374604192-5-7-2024-08-AS-RARZ-D52T4J-20240507142400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604192
Report Date: 05/07/2024
Date Signed: 05/07/2024 02:24:06 PM

Document Has Been Signed on 05/07/2024 02:24 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	OCEANSIDE REST HOME, INC		FACILITY NUMBER:	374604192
ADMINISTRATOR/ DIRECTOR:	NAVASAK, SIERA		FACILITY TYPE:	740
ADDRESS:	4451 SAN JOAQUIN STREET		TELEPHONE:	(760) 822-6182
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 6	DATE:	05/07/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Caregiver Victoria Phongpaphanh		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Siera Navasak. The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 3 were non-ambulatory and 3 were ambulatory. 2 residents were on hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Siera Navasak and their certificate was incomplete. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 106.5 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 70 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Siera Navasak, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page…

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: OCEANSIDE REST HOME, INC	FACILITY NUMBER: 374604192
	VISIT DATE: 05/07/2024

NARRATIVE

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LPA reviewed multiple resident and staff records. Review of residents' records revealed that 3 of 6 residents had a diagnosis of dementia and did not have an updated medical assessment conducted within the last 12 months. [Administrator was provided with LIC811 Confidential Names List to identify the 3 residents] Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiency was cited for updated medical assessments and noted on the attached LIC809-D page. Technical violations for business entity status and Administrator Certificate were also issued and noted on the LIC9102TV forms.

An exit interview was conducted with Administrator Siera Navasak, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC9102TVs, and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/07/2024 02:24 PM - It Cannot Be Edited

Created By: Rebecca A Ruiz On 05/07/2024 at 02:03 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: OCEANSIDE REST HOME, INC	FACILITY NUMBER: 374604192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 3 of 6 residents who were diagnosed with dementia did not have a medical assessment which was done annually which poses a potential health risk to 3 of 6 persons in care.
	POC Due Date: 06/07/2024
	Plan of Correction
1 2 3 4	Administrator will make appointments for residents to get updated physcian's reports and will submit copies of the resident's physician reports to the Department by POC due date of 6/7/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jennifer Lott

LICENSING EVALUATOR NAME:

Rebecca A Ruiz

LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2024

LIC809 (FAS) - (06/04)

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