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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 11/22/2023
Date Signed: 11/22/2023 04:22:30 PM


Document Has Been Signed on 11/22/2023 04:22 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: 61DATE:
11/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Austin IrwinTIME COMPLETED:
04:30 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 on 11/10/2023), involving Resident #1 (R1) on 11/06/2023. [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, verifying that R1 was safe. LPA reviewed and collected copies of pertinent care records. LPA also interviewed R1 and relevant staff.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Irwin, to whom a copy of this report, 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: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023
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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