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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 04/28/2023
Date Signed: 04/28/2023 05:43:29 PM


Document Has Been Signed on 04/28/2023 05:43 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: 71DATE:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Jill McDonaldTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. 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 LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 04/25/2023. According to the LIC624: Around 4:30 AM on 04/21/2023, Staff #1 (S1) observed that Resident #1 (R1) was not present inside their bedroom. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] S1 alerted coworkers, who helped them search for R1. Staff subsequently located R1 just outside the facility’s building. R1 said they felt cold and had a minor bruise on their left elbow, but they were otherwise uninjured/unharmed, as confirmed by paramedics who later assessed R1.

During today’s visit, LPA performed a brief tour and observed the facility’s perimeter exit doors. LPA also reviewed pertinent records and interviewed R1 and relevant staff. Due to their baseline disorientation to time and place and their memory loss, R1 was unable to participate as a reliable interviewee/historian about specific details of their AWOL (absent without leave) incident. However, R1 remembered some details about incident, said their elbow felt fine, confirmed they indeed were unharmed/uninjured, and stated they would not leave unassisted in the future.

According to R1’s LIC602 Physician’s Report (dated 08/08/2022): R1’s primary diagnosis was “Dementia” and their doctor determined that they were “confused/disoriented” and were not safe to leave the facility unassisted. The Pre-Placement Assessment (dated 08/23/2020), the Functional Assessment (dated 03/18/2021), and the Needs and Services Plan which licensee prepared on R1, all corroborated that R1 had Alzheimer’s type Dementia and was not safe to leave the facility unassisted. [CONTINUED ON LIC 809-C, 1 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: 04/28/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

According to licensee’s own absentee notification plan (i.e., sections “Clinical 10 – Elopement” and “MC-PO 05 – Missing Resident” from their policy and procedure manual): when staff cannot locate/account for a given resident, they must conduct a “systematic search of the property and surrounding neighborhood” and notify “law enforcement authorities…within 30 minutes, should the resident not be located.”

According to staff interviews, and corroborated by electronic date/time stamped progress notes: On 04/21/2023, S1 saw R1 asleep inside their bedroom around 3:30 AM. Around 4:30 AM, S1 returned to the bedroom but could not find R1. S1 alerted coworkers, who started searching for R1. Law enforcement was not called to assist. Around 6:06 AM, staff found R1 sitting on the ground outside the building near an exit stairwell, unharmed/uninjured except for a minor elbow bruise. It was not until after R1 was located (i.e., after 6:06 AM) that facility staff first called 911. Paramedics physically assessed R1, who (along with their responsible party) declined transportation to the hospital. CCLD concluded that facility staff did not follow the facility’s absentee notification policy during this incident, resulting in law enforcement search resources not being leveraged to help find R1. Records showed that after the incident, based on reassessment, R1 relocated to the facility’s secured memory care section on 04/22/2023.

Within the facility’s assisted living section (located on the 2nd and 3rd floors): LPA observed two unlocked (2) perimeter exit doors (accessed via unlocked stairwells near Room 202 and Room 235, respectively). Absent from each of these doors was either an "auditory device" or other "staff alert feature.” Staff interviews further revealed: the facility’s receptionist desk (which has line of sight to three perimeter exit doors located in the lobby) is normally manned/supervised between the hours of 8:00 AM and 8:00 PM. After 8:00 PM, two (2) of the three (3) lobby perimeter doorways are locked from the inside, but one (1) doorway (i.e., the main entrance) remains unlocked from the inside, as is consistent with the facility's approved fire clearance, but does not feature an “auditory device” or other “staff alert feature” being armed/used. Per LPA observation, record review, and staff interviews: during the AWOL incident in question, R1 lived in the facility’s assisted living section and had direct access to both of the above stairwell doors and the main lobby entrance door.

[CONTINUED ON LIC 809-C, 2 of 2]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 04/28/2023
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Within the facility’s secured memory care section (which licensee calls “Legacies” and located on the 1st floor): LPA observed one (1) delayed-egress door gate (located inside the Legacies courtyard) which did not have the required sign described in California Health and Safety Code (HSC). LPA also observed that three (3) interior delayed-egress doors had the required signs, but the placement/position of the signs themselves did not meet HSC requirements. LPA also observed that multiple living units located inside the facility’s memory care section did not feature pull cords or a similar “signal system,” as required. Per interview of facility management, the living units inside the memory care section did not feature such devices.

During today's visit, LPA, accompanied by facility management, tested the operation and alarms of multiple delayed egress doors. In all instances, staff responded to the door locations quickly to investigate the source of the alarms.

Two (2) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with McDonald, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/28/2023 05:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2023
Section Cited

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1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…”
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Licensee stated they plan to do formal coaching/counseling with S1. Licensee agreed to retrain its staff at large on its absentee notification plan.. Licensee agreed to E-mail LPA a copy of S1's coaching, and a copy of the training sign-in sheet, before the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not comply with the facility’s absentee notification plan for 1 of 71 residents (R1), which posed a potential safety risk to persons in care.
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Type B
05/28/2023
Section Cited

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1569.699 Exit doors; egress-control devices of time-delay type; fences: "(a)(7)(A) A sign shall be provided on the door located above and within 12 inches of the panic bar or other door-latching hardware reading: 'KEEP PUSHING. THIS DOOR WILL OPEN IN __ SECONDS. ALARM WILL SOUND..'"
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Licensee agreed to install and/or reposition signs (which meet the requirements of California Health and Safety Code) above and within 12 inches of the panic bar or other door-latching hardware, for the four (4) “Legacies” delayed-egress doors described in the visit report. Licensee agreed to E-mail LPA before the POC due date, to notify him these signs are in place and are ready to be inspected.
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This requirement was not met, as evidenced by: Based on observation, licensee did not provide signs meeting regulatory requirements on its delayed-egress doors, within an area of the facility where 24 of 71 residents (Resident #1 through Resident #24) resided, which posed a potential safety risk to persons 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/28/2023 05:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2023
Section Cited

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87303 Maintenance and Operation: “(i)(1) All facilities licensed for 16 or more and all residential facilities having separate floors…shall have a signal system which shall: (A) Operate from each resident’s living unit.” This requirement was not met, as evidenced by:
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Licensee agreed to install signal devices which: a) Can be operated from each living unit located within its “Legacies” memory care unit, b) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff, and c) Identify the specific resident living unit. Licensee agreed to E-mail LPA before the POC due date, to notify him that these signal devices are in place and ready to be inspected.
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Based on observation and interview, licensee did not have a signal system which operates from each resident's living unit, within an area of the facility where 24 of 71 residents (Resident #1 through Resident #24) resided, which posed a potential safety and personal rights risk to persons in care.
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Type B
05/28/2023
Section Cited

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87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by:
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Licensee agreed to install and/or program auditory devices (or similar staff alert devices) on the following doors: a) Exit Door via AL Stairwell near Room 202, b) Exit Door via AL Stairwell near Room 235, and c) Main Lobby Front Door during hours of 8:00 PM to 8:00 AM. Licensee agreed to E-mail LPA before the POC due date, to notify him that such devices are ready to be inspected.
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Based on records and interviews, the licensee did not have an auditory device or other staff alert feature to monitor exits, which posed a potential safety risk to 1 of 71 residents (R1) 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5