374602302-10-30-2025-08-AS-NPAN-DMY79V-20251030212834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602302
Report Date: 10/30/2025
Date Signed: 10/30/2025 09:30:48 PM

Document Has Been Signed on 10/30/2025 09:30 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:	LA COSTA HEIGHTS ASSISTED LIVING		FACILITY NUMBER:	374602302
ADMINISTRATOR/ DIRECTOR:	LINDU NAPITUPULU		FACILITY TYPE:	740
ADDRESS:	3111 LEVANTE ST		TELEPHONE:	(760) 634-2870
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY: 6		CENSUS: 6	DATE:	10/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Licensee Lindu Napitupulu		TIME VISIT/ INSPECTION COMPLETED:	04:50 PM

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Licensee Lindu Napitupulu. The facility's license shows a maximum capacity of six (6) non-ambulatory residents, ages 60 and above with a Hospice waiver for four (4). During today’s inspection there were six (6) residents in care.

LPA and Licensee Lindu Napitupulu toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Licensee Lindu Napitupulu, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview and Plan of Correction was jointly developed with the licensee Lindu Napitupulu, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Nacole Patterson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

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 10/30/2025 09:30 PM - It Cannot Be Edited

Created By: Nacole Patterson On 10/30/2025 at 03:54 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: LA COSTA HEIGHTS ASSISTED LIVING	FACILITY NUMBER: 374602302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as a pair of scissors were observed unsecured and unattended on the dining room table. This posed a potential safety risk to 6 of 6 persons in care.
	POC Due Date: 11/28/2025
	Plan of Correction
1 2 3 4	Licensee agreed to retrain staff on safety protocols for dementia residents- all sharp objects must be locked in drawers when not using. Proof of training will be provided by in-service training sign-in sheet by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Nacole Patterson
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

LIC809 (FAS) - (06/04)

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