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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 06/29/2021
Date Signed: 06/30/2021 11:22:21 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: 21DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mark Alsop, AdministratorTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Laarni Santiago visited the facility to conduct an annual required licensing inspection. LPA was granted entry into the facility and met with Mark Alsop, Administrator, with whom she discussed the purpose of the visit.

During today's visit, LPA toured the facility, and verified compliance with infection control practices. LPA and Mark Alsop reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation. LPA observed two central entry point for universal entry screening; one for visitors and the other for staff; routine symptom screening initiated at entry for staff, residents, and visitors; a sign-in policy enacted for all visitors; signs posted with the facility’s visitor policy and signs in the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; available visitation areas; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of cleaning products and PPE supplies.

No deficiencies were cited during today’s visit. An exit interview was conducted with Mark Alsop, Administrator, and a copy of this report and Licensee Rights (LIC 9058 FAS 01/16) were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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