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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600578
Report Date: 07/21/2026
Date Signed: 07/21/2026 12:08:57 PM

Document Has Been Signed on 07/21/2026 12:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RANCHO PACIFICA HOMEFACILITY NUMBER:
374600578
ADMINISTRATOR/
DIRECTOR:		CHRISTINA GRUBBSFACILITY TYPE:
735
ADDRESS:1229 RANCHO PACIFICA PLACETELEPHONE:
(760) 758-9614
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 6DATE:
07/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:ADMINISTRATOR, BRENDA A CRUZTIME VISIT/
INSPECTION COMPLETED:
12:16 PM
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On July 21, 2026, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility to conduct the Annual Inspection and met with the Administrator, Brenda Cruz. The facility file review was conducted in the Regional Office, and additional forms were reviewed at the facility. The facility is licensed for six Adult Residents and is operating within the scope and capacity of the license, for a 735 facility type. LPA Mixson toured the facility along with the Administrator, Brenda Cruz and inspected the facility inside and outside. There was no observed obstruction or debris blocking the indoor or outdoor passageways at the time of this visit. The facility has a van with a lift, and the registration is current and up to date at present. The facility phone number is (760) 758-9614 and is operable. LPA observed four resident bedrooms, and each was equipped with required furniture as per Title 22. LPA inspected facility bathrooms, and the hot water temperature was tested and logged today. The bathrooms had working appliances and were clean. The facility's smoke detectors, carbon monoxide alarms, and fire extinguishers were observed and operable. LPA observed required postings. The cleaning supplies and sharp items were locked and inaccessible in the kitchen. A designated storage space for files was locked the overall facility was clean, the furniture was in good condition, and free of pest or insects at the time of this visit. The facility cooling system and other appliances were operable currently and the facility temperature met regulations. There were safety lights for night throughout the facility and liquid soap and paper towels for hand washing. Medications were reviewed and found to be in their original contains and labeled.
Jazmond D Harris
Venus Mixson
DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RANCHO PACIFICA HOME
FACILITY NUMBER: 374600578
VISIT DATE: 07/21/2026
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LPA observed Emergency exiting plans, telephone numbers and other required signage posted throughout the facility. The review of records confirmed that the required safety drills are conducted monthly and logged. Fire extinguishers are charged and in the green. LPA reviewed the Administrator’s certification for Brenda Cruz, and it was current at the time of this visit with an expiration date of 08/05/2026 and posted at the facility. The Administrator indicated that training is done in person monthly by a certified facilitator, and the last training was completed and found to meet regulations.

LPA Mixson reviewed staff and resident files and found required items current at the time of this visit. Training's and TB ( LIC 602) met regulations. The LPA reviewed current P&I funds and the facility safeguards for residents personals are kept separately from facility's.

Facility surfaces such as tabletops, counters, and windows were clean at the time of this visit. The use of common towels and wash clothes were discussed and identified for the residents in care. Laundry supplies were observed to be in working condition and maintained at the time of this visit. Administrator indicated that the residents attend community outings weekly and to outings of their choice. The staff schedules and LIC 500 were reviewed and discussed, and the current Register of Facility Residents was reviewed, LIC 9020 was reviewed. Health related conditions were discussed, and the facility was found to be compliant at the time of this visit. The Administrator advised that none of the residents have any of the health conditions prohibited and none of the residents require the use of oxygen at this time. The facility is a non-smocking facility and there were no firearms or bodies of water observed at the time of this visit.

There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was discussed and given to Administrator, Brenda Cruz.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Venus Mixson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC809 (FAS) - (06/04)
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