<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604542
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:15:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230824090339
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:
08/30/2023
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Austin Irwin, Executive DirectorTIME COMPLETED:
04:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility was not clean.
Facility did not have sufficient supplies.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to commence a complaint investigation. LPA was granted entry after identifying herself. LPA discussed the purpose of the visit and the basic elements of the allegations mentioned above with Austin Irwin, Executive Director (ED). During today's visit, LPA toured facility, interviewed staff, and obtained records. At the end of the visit, LPA made a determination of findings and delivered them to ED.

On August 24, 2023, it was alleged that facility was not clean, and facility did not have sufficient supplies. The Department’s investigation consisted of review of facility records, LPA observations, and interviews.

It was alleged that facility was not clean, specifically resident’s room, bathroom, and the floors. On August 30, 2023, LPA observed facility floors to be sticky with grime. LPA also observed that the room of

[Continued on LIC9099-C, page 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20230824090339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023
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
26
27
28
29
30
31
32
Resident 1 (R1 - See LIC811 Confidential Names) had a strong smell of urine and a badly stained carpet. ED stated that the facility currently only had one housekeeper employed for the past two weeks. Facility document dated August 21, 2023 indicated that the rooms and common areas in Memory Care had not been cleaned in over a week. Based on the evidence obtained, the allegation that facility was not clean is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred.

It was also alleged that facility did not have sufficient supplies, specifically gloves, detergent, and toilet paper. On August 30, 2023, LPA observed a supply cabinet with sufficient toilet paper. LPA observed that laundry rooms had enough powdered detergent for immediate use but did not observe excess or backup supplies of laundry detergent. LPA did not see a supply of hand soap. Staff could not show LPA where the excess hand soap or laundry detergent was kept. ED stated that he had been told by staff on August 30, 2023 that more supplies were needed, specifically paper towels. Maintenance Director stated that paper towels had been ordered today and would arrive by tomorrow. LPA observed that there were no paper towels in the dispensers on all floors. Based on the evidence obtained, the allegation that facility did not have sufficient supplies is found to be SUBSTANTIATED.

Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with ED. An exit interview was conducted with ED; a copy of this report and Licensee's Rights (LIC9058) were provided.












[Continued from LIC9099, Page 2 of 2]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230824090339

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:
08/30/2023
UNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Austin Irwin, Executive DirectorTIME COMPLETED:
04:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility was in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to commence a complaint investigation. LPA was granted entry after identifying herself. LPA discussed the purpose of the visit and the basic elements of the allegation mentioned above with Austin Irwin, Executive Director (ED). During today's visit, LPA toured facility, interviewed staff, and obtained records. At the end of the visit, LPA made a determination of findings and delivered them to ED.

On August 24, 2023, it was alleged that facility was in disrepair, specifically the dishwasher and kitchen sinks. The Department’s investigation consisted of review of facility records, LPA observations, and interviews.

On August 30, 2023, LPA toured the kitchen located on the second floor. LPA observed that the dishwasher

[Continued on LIC9099-C, Page 1 of 2]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20230824090339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023
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
26
27
28
29
30
31
32
was in use and two different kitchen staff stated that dishwasher worked very well. LPA observed that the kitchen had two sinks and one hand-washing station. One of the sinks had two faucet handles for hot and cold water. One of the faucet handle did not produced water and only produced hot water. The other sink had working faucet handles and produced cold and hot water.

Based on the evidence obtained during the complaint investigation, the allegation that facility was in disrepair is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with ED and a copy of this report and Licensee's Rights (LIC9058) were provided.






















[Continued from LIC9099-A, Page 2 of 2]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230824090339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
MAINTENANCE AND OPERATION: (a) The facility shall be clean…at all times… This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility has hired two more houskeepers and are waiting clearance. Executive Director (ED) agreed to send pictures of room 308 and memory care floors. ED agreed to send cleaning schedule and logs.
8
9
10
11
12
13
14
Based on observation, interview, and record review the licensee did not keep the facility clean in 62 of 62 persons in care which poses a potential Health and Personal Rights risk.
8
9
10
11
12
13
14
Type B
09/15/2023
Section Cited
CCR
87307(a)(3)
1
2
3
4
5
6
7
PERSONAL ACCOMMODATIONS AND SERVICES: (a)…The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…
1
2
3
4
5
6
7
ED stated they would create an inventory log of supplies and send a copy to LPA by POC date.
8
9
10
11
12
13
14
Based on observation and interview the licensee did not have sufficient supplies in 62 of 62 persons in care which poses a potential Personal Rights risk.
8
9
10
11
12
13
14
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: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5