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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 01/06/2023
Date Signed: 01/06/2023 11:04:48 AM


Document Has Been Signed on 01/06/2023 11:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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: 50DATE:
01/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director Mark AlsopTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tammer De Los Santos conducted an unannounced case management visit. LPA was granted entry into the facility by Director Mark Alsop, to whom LPA disclosed the purpose of the visit.

This visit was initiated to cite a deficiency that is being issued in response to a self-reported incident that occurred on November 29, 2022, in which Resident #1 (R1) [see LIC 811 Confidential Names List] was absent without leave (AWOL) from the facility and was returned to the facility by local law enforcement on the same day. R1 left the facility unobserved by staff and was absent for approximately 1 hour.

It was reported to Community Care Licensing that, at approximately 5:45 AM on November 29, 2022, R1, was returned to the community by an officer of the San Diego County Sheriff’s Department. R1 was picked up by the officer at approximately 5:05AM in the local shopping center parking lot across Dove Canyon road. He was last seen at the facility at approximately 4:40AM near the kitchen door. No injuries were reported.

During today’s visit, LPA briefly toured the facility, obtained pertinent records and interviewed staff. LPA observed the kitchen door through which R1 exited with signage posted for staff.

A deficiency is being cited on the attached LIC 809-D in accordance with Title 22 of the California Code of Regulations. A Plan of Correction was developed with Director Mark Alsop. This report was discussed with the Director at the end of the visit. A copy of this report, Confidential Names List (LIC 811) and Licensee/Appeal Rights (LIC 9058) were provided at the conclusion of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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Document Has Been Signed on 01/06/2023 11:04 AM - 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: ACTIVCARE AT 4S RANCH
FACILITY NUMBER: 374603714

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2023
Section Cited

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87705(c)(4) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as
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Administrator has conducted elopement training with staff. Copies of training documents, proof of staff attendance and written policies and procedures regarding staffing levels, prevention of and response to elopements by residents were obtained during visit. POC is cleared.
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identified in his/her current appraisal. This requirement is not met as evidenced by:

AWOL Incident Report of R1. This posed a potential safety risk to one (1) resident of fifty (50) in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Tammer DeLosSantosTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
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