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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 02/14/2023
Date Signed: 02/14/2023 01:54:49 PM


Document Has Been Signed on 02/14/2023 01:54 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:PACIFICA SENIOR RANCHO PENASQUITOSFACILITY NUMBER:
374604542
ADMINISTRATOR:MCDONALD, JILLFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENASQUITOS BLVDTELEPHONE:
(858) 215-5820
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:120CENSUS: 74DATE:
02/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director, Jill McdonaldTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case Management visit. The LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director, Jill McDonald.

Today's visit was in response to an Unusual Incident/ Injury Report for Resident # 1 (R1). This report was submitted and received by the Department on 02/08/2023 [see LIC 811 Confidential Names List for a description of R1]. Additionally, the LPA toured the facility, collected pertinent records, and did not observe any immediate health, nor safety concerns. No deficiencies were cited on today's date, but additional visits may be necessary.

An exit interview was conducted with Executive Director, Jill McDonald, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC 9058) were provided to.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
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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