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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:42:07 PM


Document Has Been Signed on 11/20/2023 01:42 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, 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: 44DATE:
11/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Business Office Manager Arion RendoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Manager Arion Rendo.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/15/2023). According to the LIC624: on 11/10/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was located and brought back to the facility within two hours.

During today’s visit, LPA performed a facility tour and welfare check on R1, finding they were safe. LPA reviewed and collected copies of pertinent facility and outside source records. LPA also interviewed R1, outside sources, and relevant staff.

According to R1’s latest LIC602 Physician’s Report (dated 09/25/2023), R1 was diagnosed with dementia and their doctor determined that R1 was not safe to leave the facility unassisted.

Interviews and records showed: On 11/10/2023, staff last saw and spoke with R1 inside the facility around 4:30 PM; R1 was calm then. Sometime between 4:50 PM and 5:00 PM, staff suspected R1 was not present and began looking for them. Inside the facility’s courtyard, a bench was seen turned upright on its end, placed near the courtyard wall. R1’s walker was beside the bench. Staff timely phoned law enforcement and R1’s responsible person and expanded the search radius to the surrounding neighborhood. Police located and returned R1 to the facility around 6:30 PM. R1 had a minor scratch on one finger, and redness on a knee, but was otherwise unharmed. Licensee had a written Absentee Notification Plan as part of R1’s record of care, and staff followed this plan during the incident.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RANCH
FACILITY NUMBER: 374603431
VISIT DATE: 11/20/2023
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[CONTINUED FROM LIC 809]

No deficiencies were observed or cited during today's visit. However, LPA issued one (1) Technical Violation regarding reporting requirements.

An exit interview was conducted with Rendo. A copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC809 (FAS) - (06/04)
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