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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 12/14/2021
Date Signed: 12/15/2021 09:39:56 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: 29DATE:
12/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Executive Director Mark AlsopTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on events which licensee self-reported to the Community Care Licensing San Diego Regional Office (RO). LPA was welcomed by and identified himself to receptionist Arlene Ballow. LPA then met and discussed the purpose of the visit with Executive Director Mark Alsop.

On 12-13-2021, the RO received an LIC624 Unusual Incident Report and an LIC624A Death Report, both regarding Resident #1 (R1) [see LIC 811 Confidential Names list for a description of R1]. The reports said that on the night of 12-07-2021, R1, who has dementia and used a walker, was found on the floor of their bathroom with head trauma and without a pulse. (R1 was last seen by staff 2 hours before, in bed). 911 was called and facility staff rendered chest compressions, but first responders pronounced R1 deceased at the facility.

During today’s visit, LPA, briefly toured the facility and performed a welfare check on residents in care. LPA also obtained copies of pertinent facility care records. At the present time, the case requires further investigation. Possible follow-up telephone calls and/or visits are necessary. No deficiencies were cited on this date.

An exit interview was conducted with Alsop, to whom a copy of this report, the Confidential Names list (LIC 811), and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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