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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 07/06/2023
Date Signed: 07/06/2023 05:25:19 PM


Document Has Been Signed on 07/06/2023 05:25 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: 62DATE:
07/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Resident Services Coordinator Giovanni Arguello and Maintenance Director Singh "Andy" Wong.TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to the facility to conduct a Plan of Correct (POC) visit to confirm that a citation which was issued on 04/28/2023 has been corrected.

LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Coordinator Giovanni Arguello and Maintenance Director Singh "Andy" Wong.

The following citations were reviewed during today's visit:

87303(i)(1)(A) Maintenance and Operation: On 06/22/2023, Licensee E-mailed LPA to inform him that the signal devices in the memory care unit were operational and ready to be inspected, meeting the POC deadline. On 07/06/2023, LPA inspected and tested these devices during a site visit, finding them satisfactory.

No new deficiencies were identified or cited during today's visit.

An exit interview was conducted with Arguello, to whom a copy of this report 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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