Oceanside Rest Home II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Staff Petrada "Alice" Veopradith. Administrator Siera Navasak arrived a few minutes later. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Additionally, the facility is approved for three (3) hospice waivers. During today’s inspection there were five (5) residents in care with one (1) currently receiving hospice services. LPA and Administrator Navasak toured the interior and exterior of the facility and inspected each room. Facility sketch was consistent with the current layout of the facility. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: private bathroom sink in a dual occupancy room was 105.3F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Administrator Navasak, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. LPA observed that the fire extinguisher was last serviced in November 2024, however it remained in fair operable condition (in the green) and a Type B deficiency was issued. First aid kits were complete and readily accessible. Nearly all required licensing postings were observed in visible areas of the facility; there was no PUB 475 posting displaying contact information for anyone wishing to report a concern or complaint about any licensed facilities. LPA issued a Technical Violation (TV) and provided guidance on where the poster may be accessed and downloaded to be added to the wall. LPA interviewed one (1) client, and the interview did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA mostly contained required documents. LPA noted that four (4) resident medical assessments (commonly known as LIC 602) were outdated, with three (3) being dated for 2023 and one (1) was dated for 2024. Two (2) of those four (4) residents were diagnosed with Dementia or Mild Cognitive Impairment (MCI). A Type B deficiency was issued for the facility not obtaining updated medical assessments annually, as required. LPA additionally noted that three (3) out of five (5) residents did not have copies of Resident Personal Rights in their file, thought two (2) had signed copies. A Technical Violation (TV) was issued and consultation provided on the regulation. Confidential records were stored in locked areas. Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Administrator Navasak to whom a copy of this report, the two (2) LIC 9102 (TV) forms, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Lack of supervision resulted in resident on resident altercation.

Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to close out a complaint on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Sierra Navasak, Administrator to discuss the purpose of the visit. LPA conducted conducted a tour of the facility, and conducted interviewes. It was alleged that lack of supervision resulted in resident on resident altercation. Interviews revealed that staff there was an incident with two residents on or round 12/04/2023. Interviews revealed that Resident 1 (R1) poked R2 with a fork while at the dinner table. Interviews revealed that while the incident took place there was only one staff at the time and they were in the kitchen. Interviews revealed that the staff cannot see the table or residents from the kitchen but they could hear. Interviews revealed another resident took the fork away from R1 while at the table. Interviews revealed that on the day of the incident 2 staff were off which led the facility to only have 1 staff at the time. Interviews revealed that R1 did not go to the hospital for any injury. Based on the evidence obtained from interviews, the complaint allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is cited per Title 22 California Code of Regulation on the 9099 D page. An exit interview was conducted with Sierra Navasak, Administrator and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, May 8, 2026 · control 08-AS-20231205174438

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 21, 2026

Additional Personal Rights ... (a)…residents… shall have... the following personal rights: (4) To care, supervision, and services that meet their... needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not provide care and supervision to 1 out of 6 [R1] residents, which posed an immediate health, safety, and personal rights risk residents in care.the state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: The administrator agreed to attend training along with staff regarding topics of care and supervision. POC due to CCL by 05/21/2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year 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 Caregiver Chalongklang Rabiab. Administrator Siera Navasak arrived during the visit. The facility is licensed for a maximum capacity of 6 non-ambulatory residents and has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 4 residents, 2 of which were non-ambulatory. The Administrator for the facility is Siera Navasak and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 107.8 and 114.4 degrees Fahrenheit in common bathrooms for resident use. The facility’s internal temperature was measured at 76 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 labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The temperatures for the facility refrigerator and freezer were kept within regulatory requirements. Continued on LIC809-C page… LPA observed linens and hygiene products provided to the residents 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. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisals, and documents regarding safeguarding personal property. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. No deficiencies were cited on today’s date. An exit interview was conducted with Administrator Siera Navasak, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management 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 Caregiver Jay Elevado. LPA spoke with Administrator Siera Navasak via phone during the visit. 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, 4 of which were non-ambulatory. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Siera Navasak and their certificate is pending. 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’s water temperature was measured at 106.9 degrees Fahrenheit in a common bathroom and 106.5 degrees Fahrenheit in a private resident bathroom. LPA observed broken tiles and exposed insulation in the private resident shower and according to staff, the shower wall has been broken for at least 1 week and staff are still using the shower to bathe residents. The facility’s internal temperature was measured at 72 degrees Fahrenheit. LPA observed cleaning chemicals stored in unlocked cabinets in the facility kitchen and a private resident bathroom. Staff relocated the cleaning chemicals to locked storage during the visit. According to Elevado, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPA observed that resident medications were pre-poured into weekly pillboxes and were not in their original container. 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. Continued on LIC809-C page… 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. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, and documents regarding safeguarding personal property. 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 deficiencies for facility disrepair, pre-poured medications, and unlocked cleaning chemicals are being cited and noted on the attached LIC809-D pages. An exit interview was conducted with Caregiver Jay Elevado, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, May 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year 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 Caregiver Jay Elevado. During today's visit, LPA observed residents in care and reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Caregiver Jay Elevado, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Apr 29, 2024