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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:30:12 PM


Document Has Been Signed on 10/24/2024 04:30 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
SO. CAL AC/SC, 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: 45DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Bee Bee SmithTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Bee Bee Smith The facility serves 60 non-ambulatory residents, age 60 and above, of which 15 may be bedridden, and currently has 45 residents in care. There is an approved Hospice Waiver for 20 residents.


LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas.



No pools or bodies of water on the premises. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff/residents and reviewed multiple staff and resident records/files. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Smith, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
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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