374603431-10-16-2025-08-AS-CLOZ-DMJ2FB-20251016172115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603431
Report Date: 10/16/2025
Date Signed: 10/16/2025 05:21:39 PM

Document Has Been Signed on 10/16/2025 05:21 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:	ACTIVCARE AT ROLLING HILLS RANCH		FACILITY NUMBER:	374603431
ADMINISTRATOR/ DIRECTOR:	BONGHABIH N. SHEY		FACILITY TYPE:	740
ADDRESS:	850 DUNCAN RANCH ROAD		TELEPHONE:	(619) 482-8000
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91914
CAPACITY: 80		CENSUS: 51	DATE:	10/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:12 AM
MET WITH:	Bee Bee Smith, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by receptionist Samantha Barrientos. LPA discussed the purpose of the visit with Executive Director Bee Bee Smith. According to the facility’s license, there may be a maximum of 80 residents, all of whom may be non-ambulatory at any given time at the facility site. The facility is approved for 15 bedridden and 20 hospice residents. During today’s inspection, the facility’s current census is 51 residents living at the facility, of whom 51 were present at the facility site during the inspection. The facility comprises three sections, which may serve residents with similar care needs. LPA, accompanied by Executive Director Smith, toured the interior and exterior of the facility and inspected private shared, and individual rooms, kitchen, laundry, and maintenance areas. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings – chairs, lamps, drawers, etc. Doors, windows, toilets, and showers were in working order. LPA observed extra linens and hygiene supplies were present in the residents’ individual closets as well as the facility's linen closet. Personal Protective Equipment was present. The facility had sufficient space and equipment to facilitate dining, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 73°F. Each room had its own designated thermostat to adjust the temperature to the residents' comfort. Hot water temperature at taps accessible to residents was also compliant. Level 1: sink in a private room restroom #1 delivered hot water at 115.3°F; sink in a shared room in restroom #2 delivered hot water at 111.9°F; [CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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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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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 10/16/2025

NARRATIVE

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[CONTINUED FROM LIC 809]

sink in a private room restroom #3 delivered hot water at 106°F; sink in a shared room in restroom #4 delivered hot water at 105.3°F; Level 2: sink in a private room restroom #5 delivered hot water at 115°F; sink in a shared room in restroom #6 delivered hot water at 110.7°F; The Club: sink in a shared room restroom #7 delivered hot water at 106.2°F; sink in a private room in restroom #8 delivered hot water at 107.8°F.

There were at least 2 days of perishable food, and at least 7 days of non-perishable food present. The Facility Kitchen Manager conducts weekly orders to have ample food stock present. Cooking, dining equipment, and utensils were present, and all were safely secured and stored. The residents' dietary restrictions were managed by the facility’s Kitchen Manager, and according to the manager, staff are fully trained to ensure they are aware of residents' food restrictions. The chemicals in the kitchen area are located in a secure closet area away from food items.

There were no toxic chemicals or poisons accessible to residents. Housekeeping and laundry are managed by the facility’s Environmental Service Director. Chemicals are secured in the housekeeping carts, and carts are stored in a locked area of the facility. Laundry is conducted in a locked area of the facility, where the facility stores its laundry chemicals.

Medications were properly labeled, as required, and stored in locked areas. LPA inspected the medication room and found that medications were properly labeled and stored in a locked cabinet. The facility-maintained medication logs which LPA reviewed.

No pools on the premises, but the facility did have a fountain in the front area of the facility, which had decorative rocks inside to ensure there was no body of water accessible. Per Executive Director Bee Bee Smith, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and the facility telephone were all working. Fire extinguishers were present (08) and serviced within the last 12 months, but one fire extinguisher located in the back locked area needed to be re-serviced. First aid kits were complete (06) and readily accessible.

[CONTINUED ON LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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: ACTIVCARE AT ROLLING HILLS RANCH	FACILITY NUMBER: 374603431
	VISIT DATE: 10/16/2025

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[CONTINUED FROM LIC 809-C]

LPA briefly spoke with staff and residents and reviewed staff and resident records. LPA's visit did not raise any licensing concerns. The files that LPA reviewed contained the required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There were no deficiencies observed or cited during today's annual inspection, but technical advisories were provided and may be seen on the LIC9102 pages of this report.

An exit interview was conducted with Executive Director Bee Bee Smith to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Executive Director Smith to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E, to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Carmen Lopez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC809 (FAS) - (06/04)

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