<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 236804186
Report Date: 09/11/2026
Date Signed: 09/11/2026 11:56:02 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/11/2026 11:56 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OCEANSIDE RETIREMENT LIVINGFACILITY NUMBER:
236804186
ADMINISTRATOR/
DIRECTOR:		GYURICS, TUNDEFACILITY TYPE:
740
ADDRESS:100 S HAROLD STREETTELEPHONE:
(916) 616-7020
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY: 4CENSUS: 3DATE:
09/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Susi SusilawatiTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with caregiver Susi Susilawati and explained the purpose of the visit. Facility has a Hospice waiver for 2 residents.

At approximately 8:45AM, 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. LPA observed a hook and latch device installed at the top of the back door to prevent it from opening. The front door privacy chain was installed at the top of the door to prevent residents from opening the door. LPA instructed staff the device on the back door needed to be removed and the front door chain needs to be moved to shoulder height as designed or removed. LPA observed screw holes at the proper location where the chain was previously installed. LPA measured hot water temperature in the resident bathroom and observed it was above regulation at 121.2 degrees F. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. The common areas and bathrooms 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. LPA observed medication stored in an unsecured kitchen drawer and unsecured small refrigerator. Facility has required seven-day non-perishable and two-day perishable supply of food. 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. Facility has been conducting Emergency drills every 3 months and are overdue for a drill. The water temperature and unsecured medications are repeat violations in a 12 month period. An immediate civil penalty is being issued in the amount of $250 for each repeat violation totalling $500.

Continued on LIC809-C…

Kimberley Mota
Christopher Arnhold
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OCEANSIDE RETIREMENT LIVING
FACILITY NUMBER: 236804186
VISIT DATE: 09/11/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At approximately 9:55AM, LPA reviewed 3 resident files. 1 of 3 residents did not have a current care plan. 1 of 1 residents on Hospice did not have a Hospice care plan on file. LPA requested Licensee contact the Hospice agency to acquire a copy of the care plan. Documentation of a physician visit within the last 12 months was present. Medication records were organized and contained orders for each medication. Medications were secured in a locked cabinet with the of exception of the medication in the kitchen and refrigerator.

At approximately 10:45AM, LPA reviewed 4 staff files. 1 of 4 files reviewed did not have evidence of completed annual training. Administrator record showed the administrator certificate expired 08/6/2026. 1 of 4 records did not contain evidence of First aid/CPR training.

All employees requiring background checks are cleared.

LPA observed the facilities lease agreement expired on 7/14/2026. LPA is requesting an updated Lease agreement.

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
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 Susi Susilawati and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Christopher Arnhold
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 09/11/2026 11:56 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 09/11/2026 at 09:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE RETIREMENT LIVING
FACILITY NUMBER: 236804186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2026
Section Cited
CCR
87303(e)(2)

1
2
3
4
5
6
7
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall...attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Water Heater was adjusted during visit. Licensee agrees to monitor water temperature twice daily for seven days to ensure water temperature is within regulation. Temperature log shall be submitted to CCL by 09/23/2026.
8
9
10
11
12
13
14
Based on observation, water temperature measured at 121.2 at faucets accessible to residents, which poses an immediate Health, Safety or Personal rights risk to residents in care. This is a repeat violation in a 12 month period. An immediate civil penalty is being issued for $250.
8
9
10
11
12
13
14
Type A
09/12/2026
Section Cited
CCR87468.1(a)(6)

1
2
3
4
5
6
7
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not as evidenced by: Based on observation, the rear door and front door were secured in such a manner as to prevent residents from leaving. This poses an
1
2
3
4
5
6
7
Licensee agrees that residents have the right to leave the building. The locking devices were removed from the back door and moved to an appropriate location on the front door. Audible devices were activated. Violation cleared during visit.
8
9
10
11
12
13
14
immediate Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/11/2026 11:56 AM - It Cannot Be Edited


Created By: Christopher Arnhold On 09/11/2026 at 09:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: OCEANSIDE RETIREMENT LIVING
FACILITY NUMBER: 236804186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2026
Section Cited
CCR
87465(h)(2)

1
2
3
4
5
6
7
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, Medication was stored in an
1
2
3
4
5
6
7
Licensee agrees that all medications shall be secured and not accessible. Medication was secured during visit. Violation cleared during visit.
8
9
10
11
12
13
14
unsecured kitchen drawer and unsecured refrigerator, which poses an immediate health, safety or personal rights risk to persons in care. This is a repeat violation in a 12 month period. An immediate civil penalty is being issued in the amount of $250.
8
9
10
11
12
13
14
Type B
10/02/2026
Section Cited
CCR87405(a)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties:(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on records reviewed, the Licensee nor Administrator have a current or in process Administrator Certificate. This poses
1
2
3
4
5
6
7
Licensee agrees to ensure the facility has a certified administrator. Licensee shall submit paperwork to appoint a currently certified Administrator or evidence of current administrator certificate has been renewed. Paperwork shall be submitted by 10/02/2026.
8
9
10
11
12
13
14
a potential Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Christopher Arnhold
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5