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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 07/14/2023
Date Signed: 07/14/2023 11:44:21 AM


Document Has Been Signed on 07/14/2023 11:44 AM - 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: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: 40DATE:
07/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Office Manager Arion RendoTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Case Management Visit. LPA met with Office Manager Arion Rendo and we discussed the purpose of the visit.

Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away on 7/7/2023.

LPA conducted a wellness check at the facility, and no health or safety issues were identified. Residents observed appeared appropriate for the facility. No deficiencies were cited or observed on this date.

An exit interview was conducted with Office Manager Arion Rendo and she was provided with a copy of their appeal rights (LIC9056 03/22) along with a copy of this report.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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