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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604806
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:59:41 PM

Substantiated


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
11/05/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20251105121404
FACILITY NAME:EVEREST AT OCEANSIDEFACILITY NUMBER:
374604806
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVD.TELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:175CENSUS: 115DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Activities Director Karie WinchesterTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff handled resident(s) in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Activities Director Karie Winchester. Executive Director Jill McDonald arrived during the visit.

During today’s visit, LPA observed residents in care and interviewed residents and staff.

The Department's investigation consisted of interviews with residents and staff, review of records, and a tour of the facility. It was alleged that staff handled resident(s) in a rough manner. Review of staff personnel records and interviews with staff revealed that in July 2025, Staff 1 (S1) attempted to redirect Resident 1 (R1) during an behavioral episode and was observed to physically force R1 into a seated position.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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-20251105121404
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: EVEREST AT OCEANSIDE
FACILITY NUMBER: 374604806
VISIT DATE: 12/15/2025
NARRATIVE
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Interviews with staff and review of staff personnel records revealed that S1 was temporarily placed on disciplinary leave while the facility conducted an internal investigation, and S1 ultimately received a written warning and retraining on abuse and providing incontinence care to residents. Interviews with staff and residents did not disclose any other incidents of rough handling by staff.

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

An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20251105121404
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: EVEREST AT OCEANSIDE
FACILITY NUMBER: 374604806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2025
Section Cited
CCR
87468.1(a)(1)
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(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, residents, and other persons.
This requirement has not been met as evidenced by:
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Executive Director stated that S1 received a written warning and retraining on personal rights and abuse. Executive Director provided LPA with a copy of S1's updated training transcript and written warning during the visit.
DEFICIENCY CLEARED.
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Based on interviews and records review, the licensee did not comply with the section cited above in that R1 was physically forced to sit down, which poses a potential personal rights risk to 115 of 115 residents.
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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: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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
11/05/2025 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20251105121404

FACILITY NAME:EVEREST AT OCEANSIDEFACILITY NUMBER:
374604806
ADMINISTRATOR:MCBRIDE, FERLINAFACILITY TYPE:
740
ADDRESS:3500 LAKE BLVD.TELEPHONE:
(760) 414-9411
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:175CENSUS: 115DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Activities Director Karie WinchesterTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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2
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9
Staff yelled at resident
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Activities Director Karie Winchester. Executive Director Jill McDonald arrived during the visit.

During today’s visit, LPA observed residents in care and interviewed residents and staff.

The Department's investigation consisted of interviews with residents and staff, review of records, and a tour of the facility. It was alleged that staff yelled at resident. Interviews with residents did not disclose any concerns about staff speaking inappropriately, cursing, yelling, or screaming. Staff interviews revealed that some staff were reported to speak in a loud and excited manner, but clarified that staff did not curse or speak in an angry, rude, or disrespectful tone.
Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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-20251105121404
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: EVEREST AT OCEANSIDE
FACILITY NUMBER: 374604806
VISIT DATE: 12/15/2025
NARRATIVE
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Residents stated that staff were pleasant, considerate, and helpful and did not disclose any concerns or complaints regarding staff interactions. Interviews with staff did not reveal any complaints of staff behaviors or any staff that received disciplinary action for yelling or cursing towards residents.

The Department has investigated the above-mentioned allegation and based on interviews, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Executive Director Jill McDonald, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5