374603431-10-27-2023-08-AS-AROS-CWZU6X-20231027151905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:19:12 PM

Document Has Been Signed on 10/27/2023 03:19 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:	ACTIVCARE AT ROLLING HILLS RANCH		FACILITY NUMBER:	374603431
ADMINISTRATOR:	BONGHABIH N. SHEY		FACILITY TYPE:	740
ADDRESS:	850 DUNCAN RANCH ROAD		TELEPHONE:	(619) 482-8000
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY:	60	CENSUS: 41	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director, Bonghabih Shey Smith,		TIME COMPLETED:	03:30 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, made an unannounced visit to conduct the required One-Year Inspection. LPA Rodgers was granted entry into the facility by Executive Director, Bonghabih Shey Smith, after identifying herself and stating the purpose of the inspection. The facility serves 60 non-ambulatory residents, age 60 and above, of which 15 may be bedridden, and currently has 41 residents in care. There is an approved Hospice Waiver for 20 residents. This is a one-story complex, comprised of four (4) wings and equipped with fully secured perimeters. LPA was accompanied by the Executive Director Shey Smith, during a tour of the facility, which was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. There is a fire signal system in place and the carbon monoxide detectors were operational. The last disaster drill was conducted on October 2023. There is a water fountain located outside the entrance of the facility and made inaccessible with rocks filling the large pool of water at the base of the fountain. Exterior and interior passageways were free from obstructions. According to Executive Director Shey Smith, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident units that were tested for functionality. Resident's room temperatures were within a comfortable range. Continued on 809-C

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 10/27/2023

NARRATIVE

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Continued on 809

Each resident had clean and sufficient bed linens, towels, and washcloths. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid strips were present in residents’ showers. Community showers was clean and in working order. Hot water temperature in residents’ bathrooms were compliant.

Facility has a two-day supply of perishable and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closets. The medication room is secured and has a locked medication cart, medications were labeled and kept in compliance with label instructions.

LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained all required documents. LPA Rodgers also conducted a thorough review of In-service training procedures. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted and a copy of this report and Licensee/Appeal Rights - LIC 9058 (rev. 01/16) were provided to the Executive Director Shey Smith, whose signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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