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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 06/07/2024
Date Signed: 06/07/2024 09:31:55 AM


Document Has Been Signed on 06/07/2024 09:31 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
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: 43DATE:
06/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Executive Director Bonghabih SmithTIME COMPLETED:
09:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Bonghabih Smith.

Today's visit was in response to a licensee self-reported medication error. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 4/11/2024. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 4/10/2024 staff (S1) administered resident’s (R1) medication. Prescription stated that R1 is to receive two (2) tablets, R1 was given one (1) pill instead due to the bubble pack only containing one pill. Medication error was acknowledged, and staff requested that pharmacy send correct bubble pack dose.

During today’s visit, LPA performed a brief welfare check on residents, finding no safety concerns. LPA conducted interviews and reviewed records. Interview revealed that on 4/10/24, S1 overlooked the fact that the bubble pack contained one pill instead of 2 and incorrect dosage was administered to R1. On 4/15/2024, S1 was written up for “disregarding safety rules & practice” and counseled on 7 rights of medication administration.

One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Executive Director.

An exit interview was conducted with Executive Director, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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


Document Has Been Signed on 06/07/2024 09:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RANCH
FACILITY NUMBER: 374603431

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2024
Section Cited
CCR
87465(c)(2)

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(c) If the resident's physician has stated... that the resident is unable to determine his/her own need for nonprescription PRN medication,... facility staff...shall be permitted to assist the resident with self administration, provided...: (2) Once ordered by the physician the medication is given according
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Executive Director will ensure that S1 recieve's training on medication administration. Administrator will provide LPA with documentation of training to LPA by POC due date.
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Based on records and interviews, the licensee did not ensure that 1 of 43 residents were assisted as needed with prescription medications per physician's order on 4/10/2024, which posed a potential health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alyssa RamirezTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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