Oceanside Elderly Care Home 452

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Muhammad "Zebi" . The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and over, 3 of which may be bedridden. The facility has an approved waiver for 4 hospice residents. LPA and Licensee toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. 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 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. 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 Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Licensee Muhammad "Zebi" to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Staff hit resident in care

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to deliver findings for a complaint investigation regarding the above-mentioned allegation. LPA identified themselves and met with Caregiver Carmelita Herreria. The department received a complaint on 10/10/2025 alleging, "Staff hit resident in care," meaning a resident in care suffered physical abuse from a staff member at the facility. The investigation consisted of LPA observation, records review and interviews with facility staff, resident and outside sources. [CONTINUED ON LIC 9099-C, Page 2] Unsubstantiated [CONTINUED FROM LIC 9099, Page 1] Staff Interviews revealed that Staff 1 (S1) reported that Resident 1 (R1) frequently displayed confusion and forgetfulness, often misplacing items and accusing staff of theft. S1 also noted that R1 would yell at caregivers during routine care, particularly when being repositioned in bed, and sometimes claimed she was being hurt despite staff using gentle techniques. Staff 2 (S2) described R1 as a challenging resident who often yelled during care and expressed dissatisfaction with assistance, especially during diaper changes. S2 stated that R1 was forgetful and had not witnessed any abuse at the facility. Resident Interviews revealed R1 was able to state their name and location but had difficulty orienting to time. When asked about the alleged abuse, R1 could not recall the names of any staff members involved and stated that the incident occurred at a previous facility, not the current one. R1 repeated on at least three occasions that the abuse did not happen at the current facility. R1 was unable to identify any physical injuries or locations on their body where abuse may have occurred and changed the subject when prompted. R1 also made a threatening statement toward caregivers during the interview. Outside Source Interviews revealed Outside sources (OS1, OS2, and OS3) consistently reported that R1 has a history of making unsubstantiated claims, including past allegations of abuse against family members that were investigated and found to be unfounded. OS1 and OS2 confirmed that law enforcement and APS visited the facility and found no evidence of abuse. OS1 noted that R1 denied any abuse during the law enforcement visit and expressed confidence in the facility’s reporting practices. OS2 stated that R1’s cognitive condition contributes to their behavior and expressed general satisfaction with the care provided. OS3 also confirmed that they had never observed any mistreatment of R1 and believed the staff were attentive. Records Review revealed that in the Preplacement Appraisal (Dated 04/03/2025), R1’s diagnoses included vascular dementia and psychotic disturbance. Indicates R1 is non-ambulatory, forgetful, and requires full assistance with ADLs. This corroborates staff and outside source interviews. Based on interviews, record reviews, and direct LPA observations, there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Caregiver tCarmelita Herreria, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 08-AS-20251010163243

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Licensees Dr. Mohammed Rahman & Zebi Alvi. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, three (3) of whom may be bedridden. Hospice waiver for four (4). During today’s inspection there were six (6) residents in care. LPA with Licensee Rahman toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee Alvi, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with Licensees Rahman and Alvi to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 16, 2025

Allegation investigated: -Licensee did not meet requirements regarding observation of resident. -Licensee did not meet other reporting requirements. -Licensee did not meet requirements related to resident room change.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit. The Complainant alleged that Licensee and their staff did not provide needed observation to Resident #1 (R1), that Licensee did not meet reporting requirements related to incidents affecting R1, and that Licensee did not uphold R1’s personal rights as it related to a room change/transfer. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] CCLD’s investigation involved an unannounced facility tours/welfare checks and interviews of pertinent facility staff and outside sources. The Department also reviewed relevant care records. LPA attempted to interview R1 and each of their housemates, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. [CONTINUED ON LIC 9099-C, 1 of 3] Substantiated [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. Care records and interviews aligned to show that R1 was memory-impaired, wheelchair-bound, took blood-thinner medication, had very fragile skin, had a history of being prone to bruising and skin tears, 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, one of these managers also acknowledged that the overnight staff (who are alone on duty) were also allowed to themselves nap in between their incontinence check rounds, and that there was typically a period from around “10:30 PM or 11:00 PM” to around “4:00 AM to 5:00 AM” daily when the overnight staff were allowed to sleep. 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 was not being visually checked on. According to caregiver interviews: Around 7:00 AM on 07-26-2024, Caregiver Staff #1 (S1), who had just started their work shift, went to R1’s bedroom and first observed that R1 had a raised bump on their forehead and a skin tear on their neck that had bled. While R1 was still in bed, there was some dried blood on their pillow, and several other pillows were on the floor beside their bed. Caregiver Staff #2 (S2) was the lone staff on duty during the preceding overnight shift. Per interview of S2: They had last checked on R1 around 5:00 AM, finding nothing out of the ordinary. They denied R1 having fallen out of bed. They did not have a clear explanation for R1’s injuries. They mentioned R1 briefly screamed when S1 was in the room alone with R1. LPA asked, but S2 did not believe that S1 harmed R1 during the encounter. Per interview of S1: They denied harming S1 or causing any skin injuries during the incident. S1 had asked S2 what had occurred prior to their own arrival at work, but S2 did not have an explanation for R1’s injuries. S1 photographed R1’s injuries and bedroom, then notified R1’s responsible person. LPA tried to interview R1 about the incident, but they had no memory of it. S1 and S2 said: R1 was also unable to state to them what had happened to them. [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] LPA obtained multiple photographs (some of which were time and date-stamped), coming from multiple sources, which together showed: R1 initially had an abrasion and slightly raised bump on the middle of their forehead that was 1.5 inches wide by 1 inch long. This raised bump on R1’s forehead later lowered, and a bruise about 4 inches wide by 5 inches long formed in its place. R1 also had a bruise and a skin tear on their neck (that bled), and the blood had dried by the time it was discovered. There was also a small amount of dried blood on one pillow on R1’s bed. R1’s other four pillows were on the floor beside their bed. There was also a prominent wet stain on their bedsheet (resembling urine) about 4 feet wide by 1 foot long, where R1’s back would have been. Interviews of S1 and S2 had showed that R1 had been wearing their incontinence briefs at the time they were discovered in this condition, despite their bed being visibly wet. Then around 08-06-2024, a skin tear developed on top of a pre-existing hematoma on R1’s lower right leg. (Per the National Institutes of Health, a hematoma is a pool of mostly clotted blood that forms in a body space, such as under the skin.) CCLD obtained before and after photographs of the hematoma intact, and the subsequent skin tear, showing that at one point, the open area of skin was around 2 inches long by 1.5 inches wide. LPA interviewed pertinent caregivers, which showed that while some were aware of this injury, all interviewed were also uncertain as to how it was caused. Although R1’s 07-26-2024 and 08-06-2024 injuries were timely reported to R1’s responsible person, staff and outside source interviews clearly showed that Licensee did not notify either R1’s physician or R1’s nurse practitioner about the above incidents/injuries involving R1. By the time the complaint was filed and CCLD began investigating, R1’s forehead abrasion had healed, their forehead bruise had faded, their neck skin tear had healed, and their lower right leg skin tear had scabbed over and healed, yet 2 of 2 facility Licensees/managers and 2 of 5 caregivers (who directly cared for R1) interviewed were still unaware that these injuries to R1 had earlier occurred. There was also no written documentation of these specific injuries to R1 in the facility’s records, as was required. LPA reviewed the CCLD San Diego Regional Office’s files, finding that Licensee did not submit written incident reports regarding the above injuries to R1 (which was required to be done within seven days of incident occurrence). Incident reports were also required to be sent to R1's responsible person, and interviews showed that was also not done. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] Interviews of Licensees/managers, caregivers, and outside sources also confirmed: After an involuntary facility transfer (which CCLD cited during a separate complaint investigation), Licensee placed R1 into a certain bedroom at Oceanside Elderly Care Home 452 during late July 2024. However, around 08-02-2024, Licensee again moved R1, this time to a different bedroom within the facility, without providing advance written notice to R1’s responsible person or securing their consent. R1 was not cognitively capable of consenting to this room change. Per interviews of Licensees/managers and corroborated by LPA observation: R1 (who was an existing resident) was moved to a different room to make way for a brand-new resident who was moving in, and who themselves desired the bedroom that R1 was already occupying. Both bedrooms were private (non-shared) and there was no emergency which necessitated R1’s room change/transfer. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not meet requirements regarding observation of a resident, the Licensee did not meet reporting requirements, and that Licensee did not meet personal rights requirements related to a resident’s room change. These three (3) allegations were therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D pages). 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 pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099] Per review of CCLD’s Guardian and Licensing Information System (LIS) databases, during the time frame of the complaint allegation, both S4 and S5, as well as all other current facility staff, were each fingerprinted and possessed active background clearances to work. Interviews of Licensees/managers and facility staff reiterated the same. Based on record review and interviews, the allegation that Licensee’s staff did not have current background / criminal-record clearances is Unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The Department has therefore dismissed the allegation, and no deficiency was issued for it. An exit interview was conducted with Dr. Rahman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 08-AS-20240821121136

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to contact a third-party, CCLD-approved education Vendor to arrange a retraining class. The retraining will cover Skin Care for the Elderly, 87625 Managed Incontinence, 87465 Incidental Medical and Dental Care, 87466 Observation of the Resident, 87211 Reporting Requirements, and Resident’s Personal Rights (as articulated in CCLD form LIC613C-2), and will include both Licensee principals and current facility caregivers. Licensee agreed to E-mail the certificates of training completion (or similar proof) to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: As of the date of deficiency issuance, R1’s responsible person has decided to keep them in the same bedroom that they currently occupy (and to not go back to the former bedroom). Licensee agreed to not move R1 to a different room again, without first observing the regulatory requirement. Licensee agreed to observe the same for Resident #2 (R2). These actions resolve the deficiency.

Allegation investigated: -Licensee neglect, contributing to skin breakdown. -Licensee did not maintain comfortable facility temperature.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit. The Complainant alleged that Licensee neglect contributed to the development of a pressure injury on Resident #1’s (R1’s) buttock during August 2024. [LIC811 Confidential Names List for a description of select person identifiers used in this report.] They also alleged that on 09-08-2024, Licensee did not maintain the facility at a comfortable temperature. CCLD’s investigation involved an unannounced facility tours/welfare checks and interviews of pertinent staff and outside sources. The Department also reviewed relevant care records. LPA attempted to interview R1 and each of their housemates about the above allegations, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. [CONTINUED ON LIC 9099-C, 1 of 3] Substantiated [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.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 08-AS-20240913120439

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87652(b)(3) · Plan of correction due date: Oct 12, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: As of the date of deficiency issuance, R1’s pressure sore has healed, resolving the immediate risk. Licensee agreed to hire (if needed) and employ additional overnight staff, such that there is daily at least one overnight awake staff on duty, for as long as there are residents at the facility who rely on staff for both mobility and incontinence care. The purpose of this is to ensure that all residents’ incontinence products will be visually checked (and if needed, changed), and those residents’ body weight can be rotated/redistributed in bed, approximately once every two (2) hours, around the clock (24/7). Licensee agreed to E-mail an updated form LIC500 Personnel Report, reflecting these changes, plus proof that caregivers were retrained on resident skin care and managed incontinence care, to LPA, by 11-11-2024. The LIC500 should realistically consider the sleep/rest needs of all staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Oct 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: By the date of deficiency issuance, Licensee had already brought and left additional portable cooling units to the facility. This action resolved the deficiency. The Plan of Correction is Satisfied.

Allegation investigated: -Licensee did not assist resident with teeth brushing. -Licensee did not ensure resident had hygiene supplies.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit. The Complainant alleged that Licensee’s staff did not assist Resident #1 (R1) with teeth brushing, and that Licensee’s staff did not ensure that R1 had hygiene supplies. [See LIC 811 Confidential Names List for a description of R1.] CCLD’s investigation involved an unannounced facility tour/welfare check to observe resident’s mouths / oral hygiene. The Department also interviewed pertinent facility staff and outside sources and reviewed relevant care records. LPA attempted to interview R1 and each of their housemates, but due to their baseline memory loss, each was unable to be qualified as a reliable historian for this case. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] In their interview, Staff #1 (S1) admitted to LPA that from around 09-10-2024 through 10-03-2024, they and their fellow caregivers were not brushing R1’s teeth (they were using mouthwash only). S1 also admitted to LPA that during this same period, R1 did not have a toothbrush or toothpaste at the facility, and that by 10-03-2024, R1 had also just run out of body wash. (There is no evidence at this time that R1’s missed any showers during the review period.) Staff interviews unanimously showed: R1’s responsible person (RP) had primary responsibility for refilling R1’s toiletry supplies as needed, and that RP was responsive/timely with this task when alerted by facility staff. However, interviews showed that during the complaint allegation time frame, facility staff did not notify the RP that R1 needed refills on toiletry supplies. (RP was since notified and brought in refills on the required items). Interview of multiple facilty staff further showed that that when residents ran low on personal supplies in the past, staff sometimes took supplies belonging to one resident to use/share for another resident, instead of alerting the appropriate responsible persons (RP) and/or facility management. During today’s inspection, LPA briefly inspected 6 of 6 resident’s mouths (with those residents’ permission), finding no evidence of bad breath or excessive tartar or food build up, at present. While Licensee maintained reserve incontinence supplies in the facility’s garage, LPA observation and staff interviews showed Licensee did not maintain toiletry supplies (such as shampoo, soap/body wash, toothpaste, toothbrushes) at the facility, as part of a reserve inventory, for instances when RPs might be delayed with resupply. Based on records and interviews, a preponderance of evidence exists to show that Licensee’s staff did not assist R1 with teeth brushing, and that Licensee’s staff did not, at all times, ensure that R1 had hygiene supplies. Both allegations are therefore Substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D 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 LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 08-AS-20241011114303

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87101(c)(3) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: As of the date of deficiency issuance, interviews show facility staff had resumed brushing R1’s teeth. This resolves the immediate risk. Licensee agreed to retrain all staff on expectations around ADL care provided to residents and around the resupply of items/supplies needed to perform ADL tasks. Licensee agreed to E-mail the training sign-in sheet to LPA, by 11-11-2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to build and maintain a reserve inventory at the facility of at least the following items: Toothbrushes, toothpaste, mouthwash, shampoo, and soap/body wash. Licensee agreed to retrain all caregivers on expectations around ADL care provided to residents and around the resupply of items/supplies needed to perform ADL tasks. Licensee agreed to E-mail the training sign-in sheet and a photograph of the reserve inventory of toiletries, to LPA, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit. During review of the residents’ care records, LPA observed, and Licensee/manager interview confirmed: For Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), Licensee did not have written proof of a negative tuberculosis (TB) test result for them, which was required before each of these residents moved-in. (During LPA’s site visit, these residents did not show signs/symptoms, observable to the layperson, of active tuberculosis infection). For R4, Licensee also did not have any LIC602 Physician’s Report (or equivalent Medical Assessment) or a LIC603 Pre-Placement Appraisal (or equivalent preadmission appraisal document) for them; these were both required to be completed before they moved in. There were also no subsequent written care appraisals on file for R4. For Resident #5 (R5), their latest LIC602 Physician’s Report (from 12/06/2019) showed they were diagnosed with Dementia by their doctor. However, Licensee did not have an updated LIC602 Physician’s Report (or equivalent Medical Assessment) or a care reappraisal completed for R5 within the last year, which was required for residents diagnosed with Dementia. For Resident #1 (R1), R2, R4, and R5, Licensee also did not have file an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”). There was also no evidence that Licensee held a care-conference meeting with their respective responsible persons (RPs) within the last twelve (12) months, as was required. Interviews of multiple RPs confirmed this. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] According to their latest respective LIC602 Physician’s Reports, at least 4 of 6 residents in care [Resident #1 (R1), R2, R4, and Resident #6 (R6)] were diagnosed with Dementia, and R3 was diagnosed with Mild Cognitive Impairment. LPA observation and interview of their RP showed that R4 also likely had Dementia. Per interviews of staff and available care records, of these residents, R1 through R6, was safe to leave the facility unassisted. During today’s inspection, LPA observed, and interview of staff confirmed: Licensee installed staff auditory alert devices on its seven (7) exterior exit doors. However, caregivers had used the switches on these devices to disable the door chimes, rendering the devices ineffective. Regulation required Licensee to maintain an auditory alert device or other staff feature to monitor these exit doors. LPA also observed that both during today’s visit and a during a prior visit, the lead caregiver, who was also acting as the administrator on duty, did not have keys to access the staff records, upon CCLD demand during normal business hours. Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). 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 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to coordinate with the physicians and/or responsible persons for R2, R3, and R4, as needed, to ensure completion of tuberculosis (TB) testing for these residents, either by PPD or Chest X-ray. Licensee agreed to place the results of such testing in the resident’s care binders beside their LIC602 Physicians Report, and to E-mail the negative TB test results to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to coordinate with the physician and/or responsible person for R4, as needed, to ensure completion of an LIC602 Physician’s Report for R4. Licensee agreed to E-mail the completed and signed LIC602 for R4 to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to coordinate with the physician and/or responsible person for R5, as needed, to ensure completion of both an LIC602 Physician’s Report and an LIC625 Appraisal/Needs and Services Plan for R5. Licensee agreed to E-mail the completed and signed LIC602 and LIC625 for R5 to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87456(a)(2) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to complete an LIC603 Pre-Placement Appraisal form on R4 and to have it signed by both R4’s responsible person and by a facility representative, after joint-review. Licensee agreed to keep this document as part of R4’s care file. Licensee agreed to E-mail the completed and signed LIC603 for R4 to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(a) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to complete an LIC625 Appraisal/Needs and Services Plan form on R1, R2, R4 and R5, and to have both signed by their respective responsible person and a facility representative, after a joint-review during a care-conference meeting. Licensee agreed to E-mail the completed and signed LIC625s for R1, R2, R4, and R5 to LPA, by the POC due date. Going forward, Licensee agreed to update the LIC625 and hold a care conference, for all residents, whenever there is a significant change in their condition, but also at least once every twelve (12) months, whichever occurs first.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(j) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: During today’s inspection, LPA, accompanied by staff, switched the staff alert devices back on for each exterior door (so that they would chime when the door is opened). Licensee agreed to retrain its current and future caregivers on the expectation for door chimes on exterior doors to remain continuously active, and to E-mail the training sign-in sheet to LPA, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to provide a set of keys to the staff who act as the administrator on duty, and which always remain at the facility, which provide them controlled access to staff records/files. Licensee agreed to send LPA a photograph of said key(s) in the designated spot at the facility where they are to be kept, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahan during the visit. Interviews of facility staff showed that that when residents were short on personal supplies in the past, staff sometimes took supplies belonging to one resident to use/share for another resident, instead of alerting the appropriate responsible persons (RP) and/or facility management. The supplies in question were paid for by those residents or their RPs, and not by the Licensee. Interviews identified at least two affected residents, Resident #2 (R2) and Resident #5 (R5). One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Nov 11, 2024

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.the state’s words, verbatim · CDSS document, Oct 11, 2024

Plan of correction: Licensee agreed to build and maintain a reserve inventory at the facility of at least the following items: Toothbrushes, toothpaste, mouthwash, shampoo, and soap/body wash. Licensee agreed to retrain all caregivers on expectations around ADL care provided to residents and around the resupply of items/supplies needed to perform ADL tasks. Licensee agreed to E-mail the training sign-in sheet and a photograph of the reserve inventory of toiletries, to LPA, by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Debbie Correia, made an unannounced visit to conduct the required One-Year Inspection. LPA Correia was greeted by, and introduced herself to, Caregiver Reclusado, then met with Licensee Muhammed and explained the purpose of the visit. The facility is licensed to serve six (6) residents aged 60 and above, all six (6) of whom may be non-ambulatory, three (3) bedridden, and four (4) residents who may be on hospice care. LPA Correia reviewed resident records were reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, and Admission Agreement, and personnel records were reviewed for First Aid/CPR certification, Criminal Record Clearance, TB clearance, and Health Screening Report, and required training. The facility carbon monoxide and smoke alarms were operable. The facilities last disaster drill was conducted on January 18, 2024. LPA Correia, accompanied by Licensee Muhammed, conducted a facility tour, and inspected resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Required postings were observed. Resident bedrooms contained the required furnishings, resident bedrooms either had private or Jack and Jill bathrooms. Resident showers were equipped with non-skid flooring and grab bars. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility was equipped with emergency lighting, and first-aid kit and manual. Medications were housed in a locked medication room. Cleaning supplies and other toxins were inaccessible to residents in care. There were no bodies of water on the facility property. Licensee Muhammed there are no firearms or other weapons on the facility premises. The facility had a 7-day supply of non-perishable and a 2-day supply of perishable food. The facility’s ambient internal temperature was compliant, at 74 Fahrenheit. The facility's hot water temperature for faucets used by residents were in compliance. Based on today’s inspection, there are no deficiencies being cited. An exit interview was conducted and a copy of this report, and Licensee Rights - LIC 9058 (rev. 01/16) will be provided to Licensee Muhammed, whose signature on this form acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 22, 2024