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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:52:21 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ACTIVCARE AT ROLLING HILLS RANCHFACILITY NUMBER:
374603431
ADMINISTRATOR:BONGHABIH N. SHEYFACILITY TYPE:
740
ADDRESS:850 DUNCAN RANCH ROADTELEPHONE:
(619) 482-8000
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:60CENSUS: 34DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Bonghabih "Bee-Bee" Shey Smith, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Manager (LPM) Denise Powell and Licensing Program Analyst (LPA) Esther Iriarte-Rendon conducted an unannounced annual required inspection on today's date. LPM and LPA were greeted at the front door and granted entry by Karen Pultorak, Program Director, after identifying themselves and disclosing the purpose of the visit. An overall tour of the facility was conducted. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other requirements most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPM reviewed with Bonghabih "Bee-Bee" Shey Smith, Administrator, the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) including the following sections: Persons in Care, Staff, Visitors, Facilities without COVID-19, Residents, Facility Plans for Infection Control, and Physical Distancing. LPM assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPM and LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy, and signs throughout the facility to prom6013129017ote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.

No deficiencies were observed during today's visit. An exit interview was conducted with Bonghabih "Bee-Bee" Shey Smith, Administrator, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 FAS 01/16) was provided via email; facility representative expressed that they would send LPA a confirmation email upon receipt of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Esther Iriarte-RendonTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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