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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602864
Report Date: 08/24/2022
Date Signed: 08/25/2022 10:50:34 AM

Document Has Been Signed on 08/25/2022 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RANCHO PACIFIC HOME CARE, INCFACILITY NUMBER:
374602864
ADMINISTRATOR:NAVASAK, BRANDONFACILITY TYPE:
740
ADDRESS:4416 SAN JOAQUIN STREETTELEPHONE:
(760) 721-5473
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Brandon Navasak, DirectorTIME COMPLETED:
04:20 PM
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Interim Regional Manager(IRM) Simon Jacob and LPA Nacole Patterson conducted an unannounced Required 1 -Year Visit. IRM and LPA identified themselves, were greeted and allowed entry into the facility by Brandon Navasak, Director. IRM discussed the purpose of the visit with Brandon, and Monica Siharath, Licensee arrived later during the visit.

IRM and LPA conducted a tour of the facility with Brandon Navasak, Director. In accordance with the Department’s Infection Control program, LPA and IRM observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

IRM and LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.

IRM and LPA spoke with Monica Siharath regarding the facility's infection control plan for Monkey Pox and LPA Patterson will provide the PIN information regarding Monkey Pox.

An exit interview was conducted with Monica, Licensee, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 01/16) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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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