Oceanview Living of San Pedro

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gain or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidence by: Based on records and interviews conducted, the licensee did not ensure appropriate assistance after R1’s initial fall on 12/13/2024. No fall prevention plan or intervention was implemented, resulting in a second fall on 01/20/2025 that caused serious injuries that led to R1’s death. This posed an immediate health, safety and personal rights risk to residents in care.

87465 Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by: Based on records and interviews conducted the licensee did not ensure that staff immediately call 911 on 01/20/2025, staff did not immediately call 911 for R1 who was complaining of pain, this posed an immediate health, safety and personal risk to residents in care.

87463 Reappraisals (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement was not met as evidence by. Based on records review and interviews conducted, the licensee did not ensure that staff did a reappraisal of R1, after an unwitnessed fall that resulted in hospitalization on 12/13/2024. This poses an immediate health, safety and personal rights risk to residents in care.

82708 The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49 This regulations was not met by the following evidence:Interviews and observations indicates the Licensee is operating a sober living entity on-site that is not part of the approved plan, posting a health and safety risk to residents

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation and interviews the conducted the right side of the sink in the 2nd floor kitchenette is clogged and draining slowly. This poses a potential health and safety risk to residents in care.

87208 The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49 This regulations was not met by the following evidence:Interviews and observations indicates the Licensee is operating a sober living entity on-site that is not part of the approved plan, posting a health and safety risk to residents

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: The licensee did not ensure residents are accorded safe and healthful accommodations, as record review and interviews revealed incomplete resident face sheets and records for R1-R6 and that staff S1 was unable to provide complete health information to first responders, posing a potential health and safety risk to residents in care.

We will move forward with dismissing the citation issued to Ocean View on Plan of Operation as facility is currently working with the department to further clarify their policies and procedures related to video surveillance and because there is no clear evidence to a health and safety concern.

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes in physical,..needs. When changes in...physical health..., the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...if any. This has not been met as evidenced by LPA's interviews and record review, the licensee did not ensure that a change in R1's physical need(s) have been reported to R1's physician which poses a potential health risk to residents in care.

87465 Incidental Medical and Dental Care...The licensee shall assist residents with self-administered medications as needed.This requirment has not been met as evidenced by: On 09/11/2024 LPA Troy Watson observed on eMAR that medications had been missed for residents 1-4 for the month of September 2024. This is a potential health and safety risk to clients in care.