374604542-10-2-2023-08-AS-DNGN-CW8UEK-20231002153117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:32:06 PM

Document Has Been Signed on 10/02/2023 03:32 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 PENASQUITOS		FACILITY NUMBER:	374604542
ADMINISTRATOR:	MCDONALD, JILL		FACILITY TYPE:	740
ADDRESS:	12979 RANCHO PENASQUITOS BLVD		TELEPHONE:	(858) 215-5820
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92129
CAPACITY:	120	CENSUS: 64	DATE:	10/02/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Executive Director Austin Irwin		TIME COMPLETED:	03:40 PM

NARRATIVE

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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 Austin Irwin.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 09/18/2023). According to the LIC624, during the evening of 09/07/2023, an error by Staff #1 (S1) led to Resident #1 (R1) not receiving one (1) of their medicines as it was prescribed. [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding that they were safe, alert, and participating in a recreational activity. LPA also interviewed pertinent staff and reviewed relevant care records.

Per their latest LIC602 Physician’s Report (dated 08/31/2023), R1 was diagnosed with Mild Cognitive Impairment and required staff assistance with taking their prescribed medications. Manager interview confirmed this.

Staff interviews, corroborated by records, showed: On 09/07/2023, S1 gave R1 two (2) tablets, instead of the prescribed one (1) tablet, for one of their medications. Licensee’s staff timely notified R1’s prescribing physician (PCP) of the error, followed PCP instructions, and provided increased observation of R1. The medication error did not result in any adverse health consequence for R1. Personnel and training records showed: Following the incident, Licensee undertook individual written corrective action and retraining with S1. On 09/21/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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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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: 10/02/2023

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[CONTINUED FROM LIC 809]

A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 a medication as it was prescribed. The incident did not result in injury or illness to R1.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation (TV) regarding Reporting Requirements.

An exit interview was conducted with Irwin, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/02/2023 03:32 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: 10/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/02/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Personnel and training records showed: On 09/13/2023, Licensee undertook individual written corrective action and retraining with S1. On 09/21/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures. These actions resolve the deficiency.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee did not assist 1 of 64 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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