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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 11:48:27 AM

Document Has Been Signed on 03/19/2025 11:48 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:
09:31 AM
MET WITH:Executive Director Wes Hebner and Business Office Manager Jennifer FloresTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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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 3/10/25 in which it was reported that Resident #1 (R1) was observed by staff to have irritation and redness on the face. The resident's relative reported that R1 had washed their face with Ajax cleaning solution left in their bathroom, thinking it was soap. R1 resides in the Memory Care unit of the facility. R1 was taken to urgent care by their responsible party, where they received treatment. R1 has two (2) follow-up appointments scheduled with their Primary Care Physician (PCP). Per the Incident Report, the Ajax solution was immediately removed from R1's room and spot checks were conducted.

Upon interview with ED Hebner, the cleaning solution had been left by housekeeping staff either the morning of the incident or evening prior. During today's visit, LPA consulted with ED Hebner and conducted a health and safety check with R1.

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 11:48 AM - It Cannot Be Edited


Created By: Arian Golbakhsh On 03/19/2025 at 10:09 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 A
04/02/2025
Section Cited
CCR
87309(a)

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(a) . . . the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances . . . and other similar items which could pose a danger to residents are in locked storage and are not left unattended . . .
This requiement is not met by:
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Licensee will submit proof of hazardous materials storage/procedures training for housekeeping staff and submit to LPA by POC due date.
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Based on file review and interviews, the Licensee did not ensure hazardous cleaning supplies were kept locked and inaccessible to residents in care, posing an immediate health and safety risk to 1 out of 71 persons 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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