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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 01/18/2023
Date Signed: 01/18/2023 12:53:45 PM


Document Has Been Signed on 01/18/2023 12:53 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
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: 50DATE:
01/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director, Mark Alsop, and Program Director, Denise NotterTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management visit. The LPA introduced himself and disclosed the purpose to Executive Director, Mark Alsop, and Program Director, Denise Notter.

Today's visit was in response to an Incident Report and a Death Certificate that was submitted to the Department, for Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1]. R1 sustained a fall on 12/12/2022, was transported to the hospital and passed away on 12/17/2022. The LPA conducted a tour of the facility and secured pertinent records. No health and safety concerns were identified and no deficiencies were cited during today's visit.

An exit interview was conducted with Executive Director, Mark Alsop, to whom a copy of this report and appeal rights (LIC9058 03/22) were provided via electronic mail. An electronic mail read receipt confirms these documents were received.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023
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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