Oceanside Care Home

Type of visit: Office

At approximately 2:00PM, Licensing Program Manager (LPM) Kimberley Mota and Licensing Program Analyst (LPA) Chris Arnhold met with Licensee Sylvester Okoro to discuss concerns with the facility. Topics discussed at todays meeting included:: Administrator oversight Annual fee's Training requirements Licensee informed Community Care Licensing (CCL) that the current administrator for Oceanside Care Home 236804088 and Oceanside Care Home 236804089 is on leave. Administrator Isaac Rolle will be able to oversee these facilities as Oceanfront Care Home 236804090 will be temporarily closed due to undergoing renovations. Licensee will provide a letter to CCL outlining their plan of relocating residents and change of administrator. Licensee stated that fee's were delayed due to do internal company policy and has been corrected. Fee's will be paid in a timely manner going forward. Training was discussed. Licensee will submit an updated training plan to CCL. No deficiencies were cited at todays meeting.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Staff do not have required training Time between dinner and breakfast is more than 15 hours

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Staff Jermaine Stuart and reviewed records. Based on a review of records, LPA observed 2 of 2 staff did not have documentation of the required 40 hours of initial training. The New Employee training log covers a total of 30 hours of training in topics such as Nutrition, Personal Care Services, Dementia Training and Medication training. The training logs were signed by Administrator Valesia Cole, however the Administrator has not been a certified Administrator for two years. LPA was not able to find training materials onsite. LPA was informed the training was completed via video. There were no staff on site with valid First Aid/CPR training during this visit. Based on interviews conducted and observations made, the evening meal was served at 5PM on 04/02/2026. LPA arrived at approximately 8:15AM on this date and observed the morning meal was not served until 8:58AM. This is beyond the 15 hour maximum between evening meal and first meal. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Jermaine Stuart and Appeal rights were given. Substantiatedthe state’s words, verbatim · CDSS document, Apr 3, 2026 · control 21-AS-20260223193121

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Apr 4, 2026

1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling:(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This requirement is not met as evidenced by: Based on records reviewed, there were no staff present with CPR training. This poses an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee shall ensure at least one staff is on duty and on the premises who has a valid First aid/CPR certification. Licensee shall schedule CPR training for S1 and submit the scheduled date to CCL by 04/04/2026.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Apr 17, 2026

1569.625 Staff training; legislative findings; contents:(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement is not met as evidenced by: Based on records reviewed, S1 did not have documented evidence of completed 40 hours of initial training and did not have evidence of the 20 hours of annual training. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee shall ensure all staff receive at least 40 hours of training in the first 4 weeks of employment and at least 20 hours of training every 12 months. Licensee shall submit self certification of completed training to CCL by 04/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555 · Plan of correction due date: Apr 17, 2026

87555 General Food Service Requirements:(1) Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day...Not more than fifteen (15) hours shall elapse between the third and first meal.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee agrees to submit self certification they have read and understood regulation 87555, General Food Service Requirements. Licensee shall submit self certification of completion to CCL by 04/17/2026.

Type of visit: Case Management - Other

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a complaint investigation. LPA met with Staff Jermaine Stuart. During this visit LPA became aware of several areas of concern: -Non-payment of Licensing fees -Administrator not being present at the facility and not having a qualified person left in their place. -Staff not receiving the required training. -Staff working more than 16 hours per day. A mandatory office meeting has been scheduled for 04/22/2026 at 2:00PM, at the Santa Rosa Regional office located at 1450 Neotomas Avenue Suite 100, Santa Rosa CA, 95405. The purpose of this meeting is to discuss the areas of concern listed above. During this visit LPA spoke with Licensee Sylvester Okoro on the telephone and informed him of these concerns and the date of the meeting. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Jermaine Stuart and Appeal rights were given.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.185(e) · Plan of correction due date: Apr 4, 2026

1569.185 Fees for license or applications; use of revenues; collected; denial or forfeiture:(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met as evidenced by: Based on records reviewed, Licensee has not paid the LIcensing fee. This poses and Immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee agrees to either pay the outstanding balance for Licensing fees or submit a closure plan. Licensee shall submit confirmation of payment or closure plan to CCL by 04/04/2026.

Type of visit: Required - 1 Year

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Staff Jermaine Stuart and explained the purpose of the visit. Administrator was out of town for an appointment. Administrator certificate is current. Facility has a Hospice waiver for 2 residents. At approximately 8:40AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen equipment was clean and in good repair. Dishware appeared to be stored in a sanitary manner. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required supply of perishable and non-perishable food. Emergency water was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. First aid kit was present. No pools/bodies of water are on the premises. At approximately 9:15AM, LPA reviewed 3 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a medical assessment within the last 12 months was present. Medication records were organized and contained orders for each medication. Medications were secured in a locked cabinet. LPA will return at a later date to review staff files.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Case Management - Incident

At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a case management visit in regards to an incident report submitted by the facility. LPA met with Caregiver Lora Monroe and reviewed records. The incident was in regards to a resident, R1, being sent to the hospital for vomiting multiple times. R1 was admitted for observation. The incident report did not contain follow up information. LPA spoke with Administrator Valesia Cole via telephone and was informed of details. R1 was admitted for urinary track infection, UTI, and released on 05/23/2025. LPA received copies of documents. No citations issued during this visit.the state’s words, verbatim · CDSS document, Nov 3, 2025

Type of visit: Case Management - Legal/Non-compliance

On 04/07/2025, Licensing Program Analyst (LPA) Chris Arnhold met with Administrator Valesia Cole for an unannounced inspection to follow up on substantiated complaint allegations; complaint number 21-AS-20231121111127. On February 29, 2024, the Department concluded an investigation which alleged that due to neglect, resident sustained multiple pressure injuries and due to staff negligence, resident sustained a leg wound infection. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident and 87468.1(a)(8) Personal Rights of Residents in All Facilities. On May 15, 2024, during a meeting via Zoom the licensee was informed that a civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Continued on LIC809-C... Per Welfare and Institutions Code §15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility not providing adequate care and supervision that resulted in hospitalization a left heel unstageable pressure injury and an infection of the wound. Today, 04/07/2025, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. Exit interview conducted. A copy of the report issued. Appeal rights provided. Valesia Coles' signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Required - 1 Year

At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Valesia Cole and explained the purpose of the visit. Administrator certificate is current. Facility has a Hospice waiver for 2. At approximately 11:10AM, LPA toured the facility to ensure the health and safety of residents in care. The facility was observed to be at a comfortable temperature. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Hot water measured within regulation. No pools/bodies of water are on the premises. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. The kitchen contained cooking/dining equipment that was clean and orderly, utensils were present. Food appears to be stored and prepared properly. Refrigerators and freezers were maintained at the proper temperature. Facility has required seven-day non-perishable and two-day perishable supply of food. Emergency water supply was present to ensure facility can be self-sufficient for 72 hours. Facility has a generator to supply power in an emergency. Emergency lighting devices were present. Facility has been conducting emergency drills every 3 months. At approximately 11:30AM, LPA conducted a review of medications. Medication is locked and not accessible. First aid kit was present. At approximately 9:35AM, LPA reviewed 3 of 3 resident files. All resident files contained the required documentation. Reappraisals were conducted within the last 12 months. Documentation of a physician visit within the last 12 months was present. At approximately 11:50AM, LPA reviewed 2 of 2 staff files. 1 of 2 files did not contain evidence of completed initial training. First Aid/CPR certification was current. All employees requiring background checks are cleared. Continued on LIC809-C... Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of control of Property, (Current Rental/Lease Agreement/Deed) LIC500- Personnel Report Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Valesia Cole and Appeal rights were given.the state’s words, verbatim · CDSS document, Feb 28, 2025

Type of visit: Office

At 9:00AM, Licensing Program Manager (LPM) Bethany Moellers and Licensing Program Analyst (LPA) Chris Arnhold held an Office meeting with Licensee Sylvester Okoro via Zoom to discuss the outcome of a complaint investigation and administrative oversight concerns at the facility. On 01/18/2024, LPA Arnhold conducted an annual inspection and found the Administrator was not present at the facility. The plan of correction was for the Licensee to ensure a certified Administrator is present at the facility during normal business hours to ensure the facility is in compliance. Written plan describing Administrator hours at facility to be submitted to CCL by POC date of 2/16/2024. LPA did not receive a written plan by the correction date. The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20231121111127 The following documents were requested during this meeting: Evidence of Liability insurance Change of Administrator documentation Board Resolution appointing new Administrator LIC500 LIC308 Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Sylvester Okoro and Appeal rights were given.the state’s words, verbatim · CDSS document, May 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(a) · Plan of correction due date: May 24, 2024

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours.This requirement is not met as evidenced by:Based on observation and interviews conducted, the licensee did not comply with the section cited above. Administrator is not present in the facility a sufficient number of hours to ensure proper facility operation.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Licensee to ensure a certified Administrator is present at the facility during normal business hours to ensure the facility is in compliance. Licensee to submit written plan detailing who and when Administrator will be present in the facility. Written plan shall be submitted to CCL by POC date of 5/16/2024.

Allegation investigated: Staff did not notify authorized representative of residents change in condition Due to neglect, resident sustained multiple pressure injuries Due to staff negligence, resident sustained a leg wound infection

At 12:15PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to deliver findings from an investigation into the above allegations. LPA met with Annaky Busch. Based on records reviewed and interviews conducted, Resident, R1, was admitted to this facility 01/12/2023. The service plan on file in the facility was dated 8/28/2023 and marked as an update, but there was no previous plan available. The service plan indicated R1 was a fall risk and staff would be available at all times to supervise movements. Facility conducted a skin assessment evaluation on 01/20/2023, with no future assessments on record. R1 was seen in the emergency room on 10/28/2023 for a laceration to the leg. CCLD did not receive a written report per regulation. Based on hospital records, R1 received sutures to close the laceration and returned to the facility with aftercare instructions. Continued on LIC9099-C... Substantiated Instructions contained a notice for R1 to return the the ER if there was any increased redness, pain or swelling, and to return in 10 days to have sutures removed. Based on interviews conducted, a previous staff person felt it was the safer for R1 if they were stay in bed while recovering. Facility did not have any documentation whether the wound was cleaned or checked from 10/28/2023 to 11/08/2023. On 11/08/2023, R1 returned to the Hospital for suture removal and was admitted for an infection of the wound. Based on hospital records, R1 was found to have several new pressure injuries since the previous visit on 10/28/2023. Based on interviews conducted, the staff responsible for resident care during this time frame left employment on 11/29/2023. LPA spoke with Administrator about changes that were made in facility operation to ensure residents are observed for changes and how staff are being trained. Administrator informed LPA they are communicating more frequently with resident care teams and responsible parties to ensure resident needs are being met. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. A copy of this report was left at facility and Appeal rights were given.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 21-AS-20231121111127

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 1, 2024

87466 Observation of the Resident:The 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. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the medical needs of R1 were met. This poses an Immedate Health risk to residents.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee to ensure staff are trained to observe and report observed changes in the condition of residents. Staff are currently receiving training. POC Cleared at time of visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Mar 1, 2024

87468.1 Personal Rights of Residents in All Facilities:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, Licensee did not inform responsible party of residents change in condition, which posed an Immediate Health risk to resident.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee to ensure resident responsible parties are informed of changes in resident condition and care needs. Facility staff are currently receiving training. POC Cleared at time of visit.

Type of visit: Required - 1 Year

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility and met with Caregiver Annakay Busch. Administrator does not live in the area and was not present at the facility. At approximately 9:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 9:45AM, LPA reviewed 2 of 2 resident records and found records contained the required documentation. Medication records are thorough and contained physician's orders for each resident. At approximately 11:00AM, LPA reviewed 2 of 2 staff records. Staff records did not contain evidence of completed CPR certification. At approximately 11:45AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills monthly. Continued on LIC 809-C... Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC308- Designation of Responsibility LIC500- Personnel Report LIC610E- Disaster Plan Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Annakay Busch and Appeal rights were given.the state’s words, verbatim · CDSS document, Jan 18, 2024