374604542-1-24-2024-08-AS-AROS-CZT3DM-20240124170947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:09:54 PM

Document Has Been Signed on 01/24/2024 05:09 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:	PACIFICA SENIOR RANCHO PENASQUITOS		FACILITY NUMBER:	374604542
ADMINISTRATOR:	MCDONALD, JILL		FACILITY TYPE:	740
ADDRESS:	12979 RANCHO PENASQUITOS BLVD		TELEPHONE:	(858) 215-5820
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	120	CENSUS:	DATE:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:			TIME COMPLETED:	05:10 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 Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Executive Director Austin Irwin, identifying herself and stating the purpose of the inspection. This facility serves one-hundred twenty non-ambulatory residents, 60 and above. Approved for Hospice waiver for 15. First floor is approved for delayed egress. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. This a three story building with three courtyards on the property. There are no water features on the property. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars and non-skid mats. Hot water temperature in residents’ bathrooms were compliant. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. The facility is operating in accordance with their fire clearance. First aid kit(s) were complete and readily accessible in the medication room. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Passageways were free from obstructions. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR RANCHO PENASQUITOS	FACILITY NUMBER: 374604542
	VISIT DATE: 01/24/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed area not assessable to residents. Centrally stored medications were properly stored and locked in medication carts and cabinets. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records were complete and compliant. Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Irwin and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant.

There are two designated activity areas used for such activities as exercise, game activities, arts/crafts, and current events. There are also gathering areas throughout the facility. At the time of visit, LPA observed one large group activities in which many residents were participating. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

No deficiencies were issued at the time of visit.

An exit interview was conducted with Executive Director Austin Irwin to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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