374603714-10-16-2023-08-AS-AROS-CWNSKJ-20231016135647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 10/16/2023
Date Signed: 10/16/2023 01:56:55 PM

Document Has Been Signed on 10/16/2023 01:56 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 4S RANCH		FACILITY NUMBER:	374603714
ADMINISTRATOR:	ALSOP, MARK		FACILITY TYPE:	740
ADDRESS:	10603 RANCHO BERNARDO ROAD		TELEPHONE:	(858) 485-8001
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	60	CENSUS: 56	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator, Mark Alsop		TIME COMPLETED:	02:00 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 to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Licensee Mark Alsop, 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 56 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 delayed egress and secured perimeters. LPA was accompanied by the Licensee Mark Alsop during a tour of the facility. Tour was conducted inside and out and included a sample of 10 resident units, the dining area, recreation rooms, and food storage areas. Signal system are in place and operational. The last disaster drill was conducted in September 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Licensee, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed Egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in locked hall closet. 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. Hot water temperature in residents’ bathrooms were compliant. continued on 809C

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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 4S RANCH	FACILITY NUMBER: 374603714
	VISIT DATE: 10/16/2023

NARRATIVE

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continued from 809

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. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. The medication room is secured and has a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions.

Staff records review verified that all staff have a current First Aid certificate and at least one staff member, per shift, has a First Aide/CPR certificate, Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current.

LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of In-service training procedures. Transportation procedures were reviewed and complaint. 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, this report was discussed with Licensee Mark Alsop copy along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the Licensee Mark Alsop.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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