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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604542
Report Date: 03/19/2025
Date Signed: 03/19/2025 11:36:30 AM

Document Has Been Signed on 03/19/2025 11:36 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:RANCHO PENASQUITOS SENIOR LIVINGFACILITY NUMBER:
374604542
ADMINISTRATOR/
DIRECTOR:		HEBNER, WESFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENASQUITOS BLVDTELEPHONE:
(858) 215-5820
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY: 120CENSUS: 71DATE:
03/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Executive Director Wes Hebner and
Business Office Manager Jennifer Flores		TIME VISIT/
INSPECTION COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Wes Hebner.

Community Care Licensing received an Incident Report on 2/24/25 in which it was reported that Resident #1 (R1) had been given an extra pill by Staff #1 (S1). Per the report, R1 does take that medication, but is typically given it in the mornings, and the extra dose was given in the evening. R1 reported on 2/17/25 that they were given the extra medication on 3/14/25. Emergency medical services (EMS) were called and Poison Control was called and consulted with. It was decided by EMS and Poison Control that R1 did not need additional medical aid. R1's responsible party was notified of the incident.

During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Hebner.

A deficiency was cited during the visit. An exit interview was conducted with Business Office Manager Jennifer Flores to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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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Document Has Been Signed on 03/19/2025 11:36 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 03/19/2025 at 10:36 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 PENASQUITOS SENIOR LIVING
FACILITY NUMBER: 374604542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2025
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Licensee will submit proof of medication re-training with S1 and submit to LPA by POC due date.
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Based on file review and interview, the Licensee did not ensure proper medication administration procedures, resulting in a medication error, posing a potential health and safety risk to 1 out of 71 residents in care.
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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:Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
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