Inspection visit

complaintOctober 11, 2024

OCEANSIDE ELDERLY CARE HOME 452License 3746038422 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

[CONTINUED FROM LIC 9099] At the time of the complaint allegation, R1 was being followed by a visiting nurse practitioner (NP), who operated as an extension of R1’s primary care physician (PCP), to help address R1’s health issues as they developed. Available care records on R1 and interviews of staff and outside sources aligned to show that R1 was memory-impaired, wheelchair-bound, wore incontinence briefs, and required staff assistance with mobility, transferring, and incontinence care, among other tasks. According to interviews of Licensees/managers, facility caregivers usually checked residents’ briefs at least once every two (2) hours, changing them if they are wet or soiled. However, Licensees/managers also acknowledged that the overnight staff (who are alone on duty) were allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 AM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were not checking on residents. Caregiver interviews varied slightly, but they generally corroborated that there was usually a window of between four (4) to six hours (6) during the overnight shift when R1’s briefs were not being checked and changed. LPA obtained multiple photographs from multiple sources, which together showed: On 08-02-2024, the skin on the area in question on R1’s buttock was closed/intact. On 08-30-2024, the top layer of skin over this same spot was broken, indicating a pressure injury had developed on R1’s buttock. There was also a small black scab inside the broken skin area. LPA also obtained a photograph, which showed during the morning of 07-26-2024, staff did not provide timely needed incontinence care to R1, as evidenced by R1’s bedsheet/mattress being visibly wet with urine (the wet spot was 4 feet by 1 foot) where R1’s back would have been. Interviews of 2 of 2 staff showed that R1 had been wearing an incontinence brief at the time they discovered them in this condition. Medical records and outside source interviews showed on 08-30-2024, R1’s PCP gave a telephone order (which R1’s NP transcribed into writing for facility staff), instructing them to perform the following interventions: Reposition/rotate R1’s body weight when in bed every two (2) hours, change R1’s incontinence briefs as soon as it is soiled, and apply Calmoseptine and Vitamin A&D ointments to R1’s buttocks. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] By 09-02-2024, a subsequent photograph showed the top layer of skin over the affected area on R1’s buttock was still open but had overall improved / showed signs of healing. Interview of outside sources showed that by 09-04-2024, the NP visited the facility to inspect R1, at which point the top layer of skin over the affected area on R1’s buttock had closed/healed, with just minor redness remaining. Review of records, confirmed by manager interview, confirmed: During the complaint allegation time frame, and even at the start of CCLD’s complaint investigation on 09-17-2024, Licensee did not possess either an LIC603 Pre-Placement Appraisal (or equivalent pre-admission care appraisal document) or an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”) on R1, as were required. [CCLD cited these issues via a separate Case Management report.] Licensees/managers were still unaware that R1 had an earlier pressure injury on their buttock, or that R1’s physician gave new orders on 08-30-2024, despite the overall improvement/healing in R1’s skin condition since that time. LPA also obtained multiple photographs of the facility’s internal digital thermometer (which had a built-in date and time display). Together, they showed: On Friday 09-06-24 around 8:04 PM, the facility’s interior air temperature was 84 F. On 09-07-2024 around 5:49 PM, the facility’s interior air temperature was 85 F. Then on 09-08-2024, around 3:39 PM, the facility’s interior air temperature was 87 F. During his 09-17-2024 site visit, LPA inspected and tested the above thermometer, comparing it against a traditional mercury-based thermometer and an infrared hand-held thermometer. LPA confirmed that the facility’s internal digital thermometer was correctly calibrated and accurate in terms of displayed temperature, date, and time. LPA also reviewed historical data from Weather.com for Zip Code 92054 (where the facility is located), finding: On Thursday 09-05-24, a daily high of 90 F was reached. On Friday 09-06-24, a daily high of 97 F was reached. On Saturday 09-07-24, a daily high of 93 F was reached. On Sunday 09-08-24, a daily high of 101 F was reached. On Monday 09-09-24, a daily high of 94 F was reached. On Tuesday 09-10-24, a daily high of 85 F was reached. On Wednesday 09-11-24, a daily high of 78 F was reached. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] According to regulation, RCFE Licensees “shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F." Interviews of an outside source showed that residents were indeed uncomfortably hot on 09-08-2024. Although the ambient outside temperature peaked on 09-08-2024 (the subject date of the complaint allegation), Zip Code 92054 still did not meet criteria for being an overall “area of extreme heat.” According to the Federal Emergency Management Agency (FEMA), “extreme heat conditions” in California are defined as “three days over 100 F.” Licensee thus remained responsible for ensuring that the facility’s internal air temperature was both “comfortable” and not in excess of 85 F during the allegation time frame. Interviews of facility Licensees/managers and outside sources, corroborated by written correspondence, showed: The facility did not have central air conditioning during the allegation time frame (nor was Licensee required to maintain such). During the afternoon of 09-08-2024, residents’ responsible persons contacted Licensees via phone with concerns regarding the heat inside the facility. While Licensees/managers timely replied via phone, they did not personally visit the facility that same day, or alert CCLD to the situation. It was not until the next day (09-09-2024) that Licensee’s staff brought two (2) more portable air conditioning units to the facility, at which point the interior of the facility had significantly cooled. During his 09-17-2024 welfare check, LPA observed multiple portable cooling units at the facility; the temperature was comfortable on that date. Based on records and interviews, a preponderance of evidence exists to show that Licensee neglect (regarding incontinence care) contributed to R1 developing a pressure injury, and that there was a day when Licensee did not maintain the facility at a comfortable temperature. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). The Department determined that one of the violations resulted in injury to a resident in care. An Immediate Civil Penalty of $500.00 was thus charged and is noted on the LIC421-IM page. Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Citations

15 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87468.1(a)(12)Type B
87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12)…to keep and use their own personal possessions, including their toilet articles…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not uphold the right of 2 of 6 residents (R2 and R5) to keep and use their own personal possessions, including their toilet articles. This posed a potential personal rights risk to persons in care.
87101(c)(3)Type B
87101 Definitions: “(c)(3) ‘Care and Supervision’ shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene…” This requirement was not met, as evidenced by: Based on interviews, Licensee did not meet the grooming/hygiene needs of 1 of 6 residents (R1). This posed a potential health and personal rights risk to persons in care.
87307(a)(3)Type B
87307 Personal Accommodations and Services: “(a) The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.” This requirement was not met, as evidenced by: Based on interviews, Licensee did not ensure that 1 of 6 residents (R1) had supplies necessary for personal care and maintenance of adequate hygiene practice readily available to them. This posed a potential health and personal rights risks to persons in care.
87412(f)Type B
87412 Personnel Records: “(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, for 9 of 9 staff (S1 through S9), Licensee did not ensure that their personnel records were available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This posed a potential safety risk to persons in care.
87456(a)(2)Type B
87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…: (2) Perform a pre-admission appraisal.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), Licensee did not have on file a completed LIC603 Pre-Placement Appraisal (or equivalent pre-admission appraisal document) to evidence that they performed a pre-admission appraisal to evaluate his/her suitability, prior to accepting the resident for care. This posed a potential health, safety, and personal rights risk to persons in care.
87458(a)Type B
87458 Medical Assessment: “(a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use form LIC602…to obtain the medical assessment.” This requirement was not met, as evidenced by: Based on records review and manager interview, for 1 of 5 residents (R4), prior to the person’s acceptance as a resident, Licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This posed a potential health, safety, and personal rights risk to persons in care.
87458(b)Type B
87458 Medical Assessment: “(b) The medical assessment shall include, but not be limited to: …results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: Based on records review and manager interview, for 3 of 5 residents (R2, R3, and R4), Licensee did not ensure that the resident had a medical assessment that also included the results of a complete examination for communicable tuberculosis. This posed a potential health risk to persons in care.
87467(a)Type B
87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” This requirement was not met, as evidenced by: Based on records reviewed and interviews, for 4 of 5 residents (R1, R2, R4, and R5), Licensee did not have on file a completed LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”), to include the resident’s preferences regarding the services provided at the facility. This posed a potential health and personal rights risks to persons in care.
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87705(c)(5)Type B
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…” This requirement was not met, as evidenced by: Based on records and manager interview, for 1 of 5 residents (R5), who was diagnosed with dementia, Licensee did not ensure that they had a medical assessment and care reappraisal done at least annually. This posed a potential health risk to persons in care.
87705(j)Type B
87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on LPA observation and staff interviews, Licensee did not continuously maintain an auditory device or other staff alert feature to monitor exits. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
87211(a)(1)(D)Type B
87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had incidents which threatened their welfare/health, and Licensee did not submit a written report of the incidents to the licensing agency and the person responsible for the resident within seven days of incident occurrence. This posed a potential health risk to persons in care.
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87466Type B
87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed for changes in physical…functioning... When changes such as…deterioration of…a 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, if any.” This requirement was not met, as evidenced by: Based on records and interviews, 1 of 5 residents (R1) had a deterioration of a physical health condition which staff observed, but Licensee did not ensure that this change was documented and brought to the attention of the resident’s physician (or their staff) and responsible person. This posed a potential health risk to persons in care.
87468.2(a)(16)Type B
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not ensure that 1 of 5 residents (R1) received written notice of room change at least 30 days in advance. The room change was not done with resident consent, or to fill a vacant bed, or due to an emergency. This posed a potential personal rights risk to persons in care.
87652(b)(3)Type A
87625 Managed Incontinence: “(b)…the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.” This requirement was not met, as evidenced by: Based on interviews and photographic evidence: For 1 of 5 residents (R1), who was incontinent, Licensee did not ensure that they were kept clean and dry. This posed an immediate health and personal rights risk to persons in care.
87303(b)(2)Type B
87303 Maintenance and Operation: “(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F…and 85 degrees F…” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not at all times maintain a comfortable temperature for residents, by cooling rooms to a comfortable range between 78 degrees F and 85 degrees F. This posed a potential health and personal rights risk to 5 of 5 residents (R1 through R5) in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 11, 2024 inspection of OCEANSIDE ELDERLY CARE HOME 452?

This was a complaint inspection of OCEANSIDE ELDERLY CARE HOME 452 on October 11, 2024. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to OCEANSIDE ELDERLY CARE HOME 452 on October 11, 2024?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderl..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·October 11, 2024