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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 12/26/2025
Date Signed: 12/26/2025 02:36:01 PM

Document Has Been Signed on 12/26/2025 02:36 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:RANCHO PENASQUITOS SENIOR LIVINGFACILITY NUMBER:
374604542
ADMINISTRATOR/
DIRECTOR:		HEBNER, WESFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENASQUITOS BLVDTELEPHONE:
(858) 215-5820
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY: 120CENSUS: 75DATE:
12/26/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Executive Director Heather Myers and Business Office Manager Jessica MalloryTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Heather Myers. LPA also met with Business Office Manager Jessica Mallory.

Today's visit was in response to three (3) written reports which Licensee self-submitted; all were received at the CCLD San Diego Regional Office on 12/24/2025. The first was an LIC624 Incident Report, describing an altercation between Resident #1 (R1) and Resident #2 (R2) on 12/09/2025, for which R1 was medically cleared at the emergency room. The second was an LIC624 Incident Report, describing R1 having an unwitnessed fall in their bedroom on 12/11/2025, for which R1 required hospitalization. The third was an LIC624A Death Report, which described R1 passing away at the hospital on 12/17/2025. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on R2 and other residents in care. LPA interviewed facility managers and collected copies of pertinent care records on R1 and R2. Per interview of the facility administrator: Hospital staff reported that R1 was very agitated while at the hospital, requiring physical restraints and new medications, and that R1 had refused to eat food and drink by mouth, from 12/12/2025 until they died on 12/17/2025.

LPA also audited the facility’s employee roster against CDSS’ Guadian System. LPA observed, and manager interviews confirmed: One (1) of one-hundred (100) employes, Staff #1 (S1), did not have a Criminal Background Clearance to work, as required. Records showed S1 was a per-diem employee who was hired on 01/10/2025. Per phone interview of S1, they had worked more than five (5) days at the facility since then. [CONTINUED ON LIC 809-C]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: RANCHO PENASQUITOS SENIOR LIVING
FACILITY NUMBER: 374604542
VISIT DATE: 12/26/2025
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[CONTINUED FROM LIC 809]

One (1) deficiency was cited today per California Code of Regulations, Title 22 (see the attached LIC809-D page). Since the violation was regarding a staff background clearance, and immediate civil penalty of $500 was assessed (refer to the LIC421-BG page). A Plan of Correction were jointly formed with the Licensee.

An exit interview was conducted with Executive Director Heather Myers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/26/2025 01:50 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/26/2025 at 01:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: RANCHO PENASQUITOS SENIOR LIVING
FACILITY NUMBER: 374604542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/26/2025
Section Cited
CCR
87335(e)(2)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department…” This requirement was not met, as evidenced by:
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S1 was not on duty today. Licensee agreed to immediately remove S1 from the work schedule and instruct them to complete LiveScan fingerprinting. This resolved the immediate risk. Licensee agreed to keep S1 off-duty until receipt of confirmation of a successful background clearance for S1 from CDSS.
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Based on record review and manager interviews, Licensee did not ensure that 1 of 100 staff (S1) obtained a California clearance or a criminal record exemption as required by the Department, prior to working in the licensed facility. This posed an immediate safety risk to 75 of 75 residents [Resident #1 (R1) through Resident #75 (R75)] 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.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/26/2025


LIC809 (FAS) - (06/04)
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