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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602864
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:05:12 PM

Document Has Been Signed on 07/30/2024 12:05 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:
07/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Caregiver Joselito CarambasTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct an annual continuation from 5/31/2024. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Joselito Carambas. Licensee Monica Siharath arrived during the visit.

The facility is licensed for a maximum capacity of 6 non-ambulatory residents. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, 2 ambulatory and 4 non-ambulatory. 2 residents were receiving hospice services. The Administrator for the facility is Brandon Navasak and their certificate was valid and current.

During visits on 5/31/2024 and 7/30/2024, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 133.0 degrees Fahrenheit in a private resident bathroom and 120.7 degrees Fahrenheit in a common bathroom. Licensee turned down the water heater during the visit and the water was remeasured at 119.8 degrees Fahrenheit before the end of the visit. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Monica Siharath, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs.
Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, INC
FACILITY NUMBER: 374602864
VISIT DATE: 07/30/2024
NARRATIVE
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Staff present at the facility during the time of the inspection had a criminal background clearance and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page.

An exit interview was conducted with Licensee 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: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2024 12:05 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 07/30/2024 at 11:51 AM
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: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water temperature in a private resident bathroom measured at 133.0 degrees F, which poses a potential safety risk to 6 of 6 residents in care.
POC Due Date: 07/30/2024
Plan of Correction
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Licensee turned down the hot water heater during the visit and the hot water in the private resident bathroom measured at 119.8 degrees F prior to the end of the visit.
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.
SUPERVISOR'S NAME:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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