374603584-12-28-2023-08-AS-AROS-CYXTX2-20231228140625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603584
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:06:32 PM

Document Has Been Signed on 12/28/2023 02:06 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 MISSION BAY		FACILITY NUMBER:	374603584
ADMINISTRATOR:	DESTEFANI, DAWN		FACILITY TYPE:	740
ADDRESS:	2440 GRAND AVENUE		TELEPHONE:	(858) 270-8000
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY:	60	CENSUS: 44	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Dawn SeStegani, Executive Director		TIME COMPLETED:	02:31 PM

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Licensing Program Analyst (LPA) Amy Rodgers conducted a 1-year Required Annual Licensing inspection. Upon displaying her identification and explaining the purpose of the visit, LPA was granted entry into the facility. LPA was greeted and escorted during the tour by Jeremy Przybylek, Family Advisor. Executive Director Dawn DeStefani later joined the visit.

The facility serves sixty (60) elderly residents; approved for forty-five (45) non-ambulatory; fifteen (15) bedridden; hospice waivers for fifteen (15) and is also approved for locked perimeters.

A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. There are four wings on site connected by one central room. Signal systems are in place and operational. PPE supplies are onsite. Passageways were free from obstructions. Facility does feature delayed egress doors or a locked perimeter.

Each resident had clean and sufficient bed linens. 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. Hot water temperature in residents’ bathrooms were compliant.

Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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 MISSION BAY	FACILITY NUMBER: 374603584
	VISIT DATE: 12/28/2023

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Facility has a two-day supply of perishable food 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. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room not assessable to residents. Centrally stored medications were properly stored and locked in cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were cited during today's annual inspection; however, technical violation was issued.

An exit interview was conducted with Executive Director DeStefani, to whom a copy of this report, the LIC 9102TVs, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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