374603584-12-27-2024-08-AS-HROS-DCCS8Y-20241227123956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603584
Report Date: 12/27/2024
Date Signed: 12/27/2024 12:40:06 PM

Document Has Been Signed on 12/27/2024 12:40 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/ DIRECTOR:	DESTEFANI, DAWN		FACILITY TYPE:	740
ADDRESS:	2440 GRAND AVENUE		TELEPHONE:	(858) 270-8000
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92109
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 0	CENSUS: 50	DATE:	12/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Program Director Bernadette Bowman		TIME VISIT/ INSPECTION COMPLETED:	12:40 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) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Program Director Bernadette Bowman. The facility's license shows a maximum capacity of 60 non-ambulatory elderly residents, of which 15 may be bedridden. Hospice waiver for 15. During today’s inspection there were 50 non-ambulatory residents in care, with 12 residents on hospice. LPA with Program Director Bowman toured the interior and exterior of the facility and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, and showers were in working order. LPA observed 8 resident showers not equipped with non-skid mats or strips. Program Director Bowman confirmed that resident showers are not equipped with non-skid flooring. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Program Director Bowman, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited in accordance with CCR Title 22. An exit interview was conducted with Program Director Bowman to whom a copy of this report, LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Hannah Rodgers	TELEPHONE: (619) 417-3928
	DATE: 12/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

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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Document Has Been Signed on 12/27/2024 12:40 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACTIVCARE AT MISSION BAY	FACILITY NUMBER: 374603584
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above in thirty (30) out of thirty-one (31) showers which poses a potential safety risk to persons in care.
	POC Due Date: 01/17/2025
	Plan of Correction
1 2 3 4	Licensee agreed to purchase and apply non-skid surface to all resident showers. Licensee will provide CCL with photographic evidence of installation by POC due date of 01/17/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Hannah Rodgers	TELEPHONE: (619) 417-3928
	DATE: 12/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

LIC809 (FAS) - (06/04)

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