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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602864
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:29:25 PM

Document Has Been Signed on 05/31/2024 02:29 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:RANCHO PACIFIC HOME CARE, INCFACILITY NUMBER:
374602864
ADMINISTRATOR/
DIRECTOR:		NAVASAK, BRANDONFACILITY TYPE:
740
ADDRESS:4416 SAN JOAQUIN STREETTELEPHONE:
(760) 721-5473
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver Victoria DequinaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rebecca Ruiz and Ryan Fulton 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 Caregiver Victoria Dequina. Administrator Monica Siharath arrived during the visit.

During today's visit, LPAs toured the facility, reviewed facility records, and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

The following deficiency regarding incontinence care was cited and noted on the attached LIC809-D page.

An exit interview was conducted with Administrator Monica Siharath, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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Document Has Been Signed on 05/31/2024 02:29 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 05/31/2024 at 01:56 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: RANCHO PACIFIC HOME CARE, INC
FACILITY NUMBER: 374602864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/14/2024
Section Cited

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87625 (b) ... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement has not been met as evidenced by:
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Based on LPA observation, the licensee did not ensure that the facility remained free of incontinence odors. This poses a potential personal rights risk to 6 of 6 residents in care.
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Administrator will submit the log to the Department by POC due date of 6/14/2024.

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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.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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