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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 06/26/2024
Date Signed: 06/26/2024 02:40:56 PM


Document Has Been Signed on 06/26/2024 02:40 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 RANCHFACILITY NUMBER:
374603714
ADMINISTRATOR:ALSOP, MARKFACILITY TYPE:
740
ADDRESS:10603 RANCHO BERNARDO ROADTELEPHONE:
(858) 485-8001
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:60CENSUS: 52DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Denise NotterTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and discussed the purpose of the visit with Executive Director Denise Notter. The facility was licensed for a capacity of sixty (60) non-ambulatory residents, of which fifteen (15) may be bedridden. The facility was also approved for delayed egress, secured perimeter, a hospice waiver for twenty (20), a waiver for a locked perimeter gate, and a waiver for non-physicians to prescribe medications.

The LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored.
Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients.
Medications were labeled, and stored in a locked area.

No pools, nor bodies of water on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon
monoxide detectors, fire extinguisher(s), and first aid kit were present . Required licensing postings were observed in a visible area of the facility.

The LPA interviewed staff and reviewed multiple staff and client records. No deficiencies were observed, nor cited during today's annual inspection.

An exit interview was conducted with Executive Director Notter, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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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