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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602864
Report Date: 08/29/2026
Date Signed: 08/29/2026 02:47:47 PM

Document Has Been Signed on 08/29/2026 02:47 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RANCHO PACIFIC HOME CARE, INCFACILITY NUMBER:
374602864
ADMINISTRATOR/
DIRECTOR:		NAVASAK, BRANDONFACILITY TYPE:
740
ADDRESS:4416 SAN JOAQUIN STREETTELEPHONE:
(760) 721-5473
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 5DATE:
08/29/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Amy Rodgers 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 with care staff Joselito Carambas. Siera Navaska also joined the visit for a brief time.

A tour of the facility was conducted, including all resident rooms, staff areas, common areas, bathrooms, kitchen, garage, and outside grounds. Due to time constraints, additional components of the annual inspection will need to be continued at a later date.

During review of medication storage and documentation, LPA observed unsecured medications, medications accessible in resident rooms, and medication records that did not match physician orders for 4 of 5 residents. LPA also observed Pre-pored containers for 5 of 6 residents in medication cart. The facility does not maintain a MAR. During review of resident records, LPA found reappraisals were not current for R2, R3, R4, and R5. During review of personnel records Staff #1(S1) and Staff #2(S2) are without current CPR/First Aid certification. Night staff (S1) also lacked required CPR/First Aid training.

Deficiencies were cited today per California Code of Regulations, Title 22 (see the attached LIC 809-D pages). Plans of Correction were discussed with Caregiver Joselito Carambas. LPA will return on a subsequent day to complete the remaining portions of the annual inspection.

An exit interview was conducted with Caregiver Joselito Carambas, to whom a copy of this report, the LIC 809-D pages, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during today’s visit.

Simon Jacob
Amy Rodgers
DATE: 08/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2026
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 6
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 6
Document Has Been Signed on 08/29/2026 02:47 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/29/2026 at 12:25 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RANCHO PACIFIC HOME CARE, INC
FACILITY NUMBER: 374602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2026
Section Cited
CCR
87463(h)(1)

1
2
3
4
5
6
7
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LPA had Staff #1 lock medication in cart and audit all Resident rooms for stored medciation and lock in medication cart. LIcensee will conduct outside source training to all staff and themselves regarding medciation storage by 9/30/2026
8
9
10
11
12
13
14
Based on observation, LPA observed medications sitting on top of the medication cart upon entry, and the cart was unlocked with keys left in the lock. During the tour, PRN and prescribed medications were observed in R2’s room and in R3/R4’s shared room, making them accessible to 4 of 5 residents. This poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
08/30/2026
Section Cited
HSC8765(h)(6)

1
2
3
4
5
6
7
(6) Centrally stored medication records shall be maintained to ensure that medication is given as prescribed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LPA will conduct audit of R1-R5 medcations to assure physcians orders prescriptions corrilate with medcations given by POC Date. LIcensee will conduct outside source training to all staff and themselves regarding medciation storage by 9/30/2026
8
9
10
11
12
13
14
Based on record review and observation, LPA found that the physician‑ordered medication lists do not match the medications maintained for 4 of 5 residents. The facility does not maintain a MAR, resulting in inaccurate and incomplete centrally stored medication records. This poses an immediate health, safety, and personal rights risk to persons 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/29/2026 02:47 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/29/2026 at 01:14 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RANCHO PACIFIC HOME CARE, INC
FACILITY NUMBER: 374602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87563(h)(1)

1
2
3
4
5
6
7

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure that R2 and R4 completes their annual routine physical/medical visit. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on observation and interview , the licensee did not comply with the section cited above in 2 of 6 (R2 and R4) which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
09/30/2026
Section Cited
CCR87463(c)

1
2
3
4
5
6
7
 The licensee shall conduct a reappraisal of each resident as frequently as necessary to ensure that the resident's needs can be met.
1
2
3
4
5
6
7
Licensee will ensure that R2-R5 completes their Re-Aprriasals by POC date,Licensee agreed to send proof of completion to LPA, by the POC due date.
8
9
10
11
12
13
14
Based on record review, LPA found that R2, R3, R4, and R5 do not have current reappraisals as required. The lack of updated reappraisals limits the facility’s ability to properly assess residents’ changing needs and ensure appropriate care. This poses a potential health, safety, and personal rights risk to persons 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/29/2026 02:47 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/29/2026 at 01:32 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RANCHO PACIFIC HOME CARE, INC
FACILITY NUMBER: 374602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87411(c)(1)

1
2
3
4
5
6
7
87411(c)(1)All personnel responsible for providing care shall have current CPR and First Aid certification.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall ensure that all staff responsible for providing care obtain current CPR/First Aid certification and submit proof of completed certification to LPA by the POC date
8
9
10
11
12
13
14
Based on record review, LPA found that (S1 and S2) staff responsible for providing care do not have current CPR and First Aid certification. This poses a potential health, safety, and personal rights risk to 6 of 6 persons in care.
8
9
10
11
12
13
14
Type B
09/30/2026
Section Cited
HSC87515(a)

1
2
3
4
5
6
7
 87415(a)Night staff shall be trained in first aid as required in Section 87465 and shall be available to assist in caring for residents in the event of an emergency.
1
2
3
4
5
6
7
Licensee shall ensure that all staff responsible for providing care at night obtain current First Aid/CPR certification and submit proof of completed certification to LPA by the POC date
8
9
10
11
12
13
14
Based on record review and interview, LPA found that night staff do not have current CPR/First Aid training as required. This poses a potential health, safety, and personal rights risk to 6 of 6 persons 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/29/2026 02:47 PM - It Cannot Be Edited


Created By: Amy Rodgers On 08/29/2026 at 02:32 PM
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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RANCHO PACIFIC HOME CARE, INC
FACILITY NUMBER: 374602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2026
Section Cited
CCR
87465(H)(5)

1
2
3
4
5
6
7
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will immediately discontinue the practice of pre-pouring medications. Licensee will retrain all staff responsible for medication assistance and medication handling, ensuring medications are dispensed only from the original pharmacy container at the time of administration. Licensee will submit proof of staff retraining to LPA by the POC.
8
9
10
11
12
13
14
Based on observation and interview, the licensee did not comply with the section cited above in 5 of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Amy Rodgers
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2026


LIC809 (FAS) - (06/04)
Page: 6 of 6