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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601258
Report Date: 08/20/2025
Date Signed: 08/20/2025 03:44:40 PM

Document Has Been Signed on 08/20/2025 03:44 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:FAIRWINDS - IVEY RANCHFACILITY NUMBER:
374601258
ADMINISTRATOR/
DIRECTOR:		SOMMER, JESSICAFACILITY TYPE:
740
ADDRESS:4490 MESA DRTELEPHONE:
(760) 439-8090
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 200CENSUS: 181DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Debbie DalaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rebecca Borunda and Jose De La Cruz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPAs were greeted by, identified themselves to, and explained the purpose of the visit with Debbie Dala, Guest Services Manager.

During today's visit, LPAs toured the facility, reviewed facility records, and observed residents in care. Review of the facility’s fire clearance dated 8/1/2002 and review of the facility’s licensed capacity revealed that the facility is approved for a maximum capacity of 200 residents, 75 of which might be non-ambulatory. Interviews with staff revealed that a majority of residents required the use of an assistive device such as a walker or wheelchair and estimated that approximately 85 residents required the use of a walker or wheelchair.

Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPAs were away from the facility for approximately thirty minutes between 1:30 pm and 2:00 pm.

The following deficiency for over capacity of non-ambulatory residents is cited per California Title 22 and noted on the attached LIC809-D page. Additionally, a civil penalty in the amount of $500 was assessed for over-capacity and noted on the attached LIC421IM form.

An exit interview was conducted with Debbie Dala Guest Services Manager, MJ Bachelor, Health and Wellness Director, whose signature below confirms receipt of a copy of this report LIC421IM and the Licensee Appeal Rights (LIC9058 3/22).
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Jose DeLaCruz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/20/2025 03:44 PM - It Cannot Be Edited


Created By: Jose DeLaCruz On 08/20/2025 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: FAIRWINDS - IVEY RANCH
FACILITY NUMBER: 374601258

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
87204 (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that 85 out of 181 residents are non ambulatory, which poses an immediate safety risk to 181 residents in care.
POC Due Date: 08/21/2025
Plan of Correction
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Health and Wellness Director will submit an updated LIC200 and an updated facility sketch requesting an increase in non ambulatory capacity to the Department by POC due date of 08/21/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Jose DeLaCruz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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