374604542-7-5-2022-08-AS-SMAZ-CG2Q9H-20220705115819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 07/05/2022
Date Signed: 07/05/2022 11:58:33 AM

Document Has Been Signed on 07/05/2022 11:58 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PACIFICA SENIOR RANCHO PENASQUITOS		FACILITY NUMBER:	374604542
ADMINISTRATOR:	CALLAGHAN, CARLINE		FACILITY TYPE:	740
ADDRESS:	12979 RANCHO PENASQUITOS BLVD		TELEPHONE:	(858) 215-5820
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	120	CENSUS: 82	DATE:	07/05/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director, Carline Callaghan, and Maintenance Director, Miguelito Uson		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance, and to conduct a Component III. The facility is undergoing a change of ownership, the fire clearance was granted on 2/10/2022, and is approved for one hundred twenty (120) residents. One hundred ten (110) residents may be non-ambulatory, and ten (10) may be bedridden. The LPA was greeted by Executive Director, Carline Callaghan and Maintenance Director, Miguelito Uson. The LPA identifying himself and disclosed the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE. Additionally, the LPA observed exterior and interior passageways were free from obstructions. All of the observed resident rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. The facility was stocked with a 2 day supply of perishable and a 7 day supply of nonperishable food items. Cleaning supplies and medications were observed to be locked in different locations and inaccessible to residents in care. Carbon Monoxide detectors were observed to be operable. No pools, nor bodies of water were observed at the facility. Per the administrator, there were no firearms at the facility on this date. The LPA discussed continuing operation requirements, record keeping, reporting requirement and physical plant compliance.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR RANCHO PENASQUITOS	FACILITY NUMBER: 374604542
	VISIT DATE: 07/05/2022

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The Pre-licensing and Component III were completed on today's date. Facility is ready to be licensed pending management approval. This is a change of ownership application and there are eighty-two (82) residents currently in care. An exit interview was conducted with Executive Director, Carline Callaghan, to whom a copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC809 (FAS) - (06/04)

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