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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 10/08/2020
Date Signed: 10/14/2020 10:38:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:ACTIVCARE AT 4S RANCHFACILITY NUMBER:
374603714
ADMINISTRATOR:ALSOP, MARKFACILITY TYPE:
740
ADDRESS:10603 RANCHO BERNARDO ROADTELEPHONE:
(858) 485-8001
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:60CENSUS: 27DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Mark Alsop, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Laarni Santiago, contacted the facility via telephone regarding a Case Management - Incident. The visit is being conducted via telephone due to COVID-19. LPA identified herself and explained the purpose of the call to Administrator, Mark Alsop.

On 08/24/20, Community Care Licensing received a self reported incident involving Resident #1 (R1) [See LIC 811 Confidential Names List to identify Resident #1]. On 08/16/20, R1 sustained a right hip fracture from a witnessed fall that occurred at the facility. During the telephone call with the Administrator, LPA briefly interviewed Administrator, requested records, and obtained additional information. No deficiencies were issued.

An exit interview was conducted with Administrator, Mark Alsop, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirms documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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