Inspection Reports for Rancho Penasquitos Senior Living
12979 Rancho Peñasquitos Blvd, San Diego, CA 92129, United States, CA
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent report on May 28, 2025, which was clean following a review related to a resident’s heat exhaustion. Earlier reports showed some substantiated complaints involving neglect that led to pressure injuries, medication errors, and failure to secure hazardous cleaning supplies, with one incident posing an immediate health risk. The facility also had issues with resident dignity and cleanliness, as well as safety concerns related to unsecured exits and delayed law enforcement notification for a missing resident. Several complaint investigations were substantiated, but many others found no deficiencies or were unsubstantiated. The pattern suggests improvement over time, with the latest inspections showing no deficiencies after addressing prior concerns.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 68
Capacity: 120
Deficiencies: 0
Date: May 28, 2025
Visit Reason
The visit was an unannounced Case Management follow-up to an incident reported to Community Care Licensing involving a resident found unresponsive due to heat exhaustion.
Findings
No deficiencies were cited during the visit. The Licensing Program Analyst conducted file review, a health and safety visit with the resident involved, and provided consultation with the Business Office Manager.
Report Facts
Incident report date: May 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kamryn Finchum | Business Office Manager | Met with Licensing Program Analyst during the visit and involved in consultation |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Jennifer Lott | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 120
Deficiencies: 3
Date: Apr 8, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-02-10 alleging neglect resulting in pressure injuries, unmet incontinence needs, and failure to provide clean linens to a resident.
Complaint Details
The complaint investigation was substantiated. Allegations included neglect causing pressure injuries, unmet incontinence needs, and failure to provide clean linens. The facility did not obtain a hospice care plan for Resident #1 and failed to follow hospice recommendations. Staff interviews and hospice notes confirmed multiple occasions of soiled briefs and linens. The facility acknowledged deficiencies and formulated Plans of Correction.
Findings
The investigation substantiated allegations that the facility neglected Resident #1, resulting in pressure injuries, failed to meet the resident's incontinence needs, and did not consistently provide clean linens. These deficiencies posed potential health, safety, and personal rights risks to residents.
Deficiencies (3)
Failure to ensure Resident #1 was free from neglect resulting in pressure injuries.
Failure to ensure incontinent residents were kept clean and dry.
Failure to ensure residents had clean linens at all times.
Report Facts
Residents in care: 71
Total licensed capacity: 120
Deficiency count: 3
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Hebner | Executive Director | Named in relation to findings and Plan of Corrections |
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Lizzette Tellez | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Follow-Up
Census: 71
Capacity: 120
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported involving a medication error where a resident was given an extra pill.
Findings
A deficiency was cited due to failure to ensure proper medication administration procedures, resulting in a medication error posing a potential health and safety risk to one resident.
Deficiencies (1)
Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by a medication error involving one resident.
Report Facts
Residents in care: 71
Total licensed capacity: 120
Plan of Correction due date: Due date for correction is 04/02/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Hebner | Executive Director | Met during inspection and discussed purpose of visit |
| Jennifer Flores | Business Office Manager | Participated in exit interview and received report |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the inspection visit |
| Jennifer Lott | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Follow-Up
Census: 71
Capacity: 120
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
An unannounced Case Management visit was conducted to follow up on an incident reported to Community Care Licensing involving a resident who was exposed to a hazardous cleaning solution.
Complaint Details
The visit was triggered by an incident report received on 03/10/2025 regarding Resident #1 who washed their face with Ajax cleaning solution left in their bathroom, resulting in irritation and redness. The resident was treated at urgent care and has follow-up appointments scheduled.
Findings
A deficiency was cited for failure to ensure hazardous cleaning supplies were kept locked and inaccessible to residents, posing an immediate health and safety risk to one resident. The cleaning solution was left unattended in the resident's bathroom.
Deficiencies (1)
The licensee did not ensure hazardous cleaning supplies were kept locked and inaccessible to residents, posing an immediate health and safety risk to 1 out of 71 persons in care.
Report Facts
Residents in care: 71
Total licensed capacity: 120
Plan of Correction due date: Due date for correcting the cited deficiency is 04/02/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Hebner | Executive Director | Interviewed regarding the incident and cleaning solution storage |
| Jennifer Flores | Business Office Manager | Participated in exit interview and received report and appeal rights |
| Arian Golbakhsh | Licensing Program Analyst | Conducted the unannounced Case Management visit and inspection |
Inspection Report
Annual Inspection
Census: 71
Capacity: 120
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
The visit was an unannounced continuation annual inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.
Findings
The inspection included interviews and record reviews, and no deficiencies were cited during this visit.
Report Facts
Licensed capacity: 120
Census: 71
Hospice care waiver capacity: 15
Bedridden resident capacity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jenny Flores | Business Office Manager | Met with Licensing Program Analyst during inspection and received report |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced continuation annual inspection visit |
| Lizzette Tellez | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 71
Capacity: 120
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The inspection was an unannounced required annual inspection visit conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, sanitary, and in good repair. Resident rooms were properly furnished, safety systems such as call pendants and carbon monoxide detectors were operational, and food and medication storage met requirements. No safety hazards or prohibited items were observed. The inspection was not completed due to time constraints and will continue on a subsequent day.
Report Facts
Licensed capacity: 120
Bedridden capacity: 10
Hospice care waiver capacity: 15
Current census: 71
Inspection start time: 1430
Inspection end time: 1630
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wes Hebner | Executive Director | Met with Licensing Program Analyst during inspection and received report |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
| Mathew Gomez | Maintenance Director | Assisted Licensing Program Analyst during inspection |
| Jenny Flores | Business Office Manager | Assisted Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 120
Capacity: 120
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
Licensing Program Analyst Amy Rodgers conducted an unannounced required one-year inspection to ensure substantial compliance with Title 22 regulations at the facility.
Findings
The facility was found to be in substantial compliance with regulations, with clean and sufficient linens, sanitary bathrooms, proper food storage, compliant medication administration, complete staff and resident records, and sufficient staffing. No deficiencies were issued at the time of the visit.
Report Facts
Hospice waiver approved residents: 15
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Rodgers | Licensing Program Analyst | Conducted the inspection and authored the report |
| Austin Irwin | Executive Director | Facility representative who granted entry and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 120
Deficiencies: 0
Date: Nov 22, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report self-submitted by the licensee involving Resident #1 on 2023-11-06.
Complaint Details
The visit was triggered by a complaint incident report involving Resident #1, with no deficiencies found and the resident verified to be safe.
Findings
During the unannounced Case Management - Incident visit, the Licensing Program Analyst performed a facility tour, welfare check, reviewed care records, and interviewed the resident and staff. No deficiencies were observed or cited.
Report Facts
Capacity: 120
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Austin Irwin | Executive Director | Met with during the visit and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint alleging that staff did not treat a resident with dignity, specifically that a staff member placed their hand over a resident's mouth and told them to be quiet.
Complaint Details
The complaint was substantiated based on evidence including staff admission and interviews. The allegation involved staff not treating a resident with dignity by placing a hand over the resident's mouth and telling them to be quiet.
Findings
The investigation substantiated the allegation that Staff #1 did not accord Resident #1 dignity in their personal relationship, violating company policy and posing potential health, safety, and personal rights risks. In-service training on elder abuse was provided to all staff after the incident.
Deficiencies (1)
87468.1 Personal Rights of Residents in All Facilities(a)(1) Residents shall be accorded dignity in their personal relationships with staff, residents, and others. This requirement was not met as evidenced by Staff #1 placing their hand over Resident #1's mouth and telling them to be quiet.
Report Facts
Capacity: 120
Estimated Days of Completion: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sabel Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Austin Irwin | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 120
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
The visit was conducted in response to an LIC624 Incident Report regarding a medication error where a resident did not receive one of their prescribed medicines as required.
Complaint Details
The visit was complaint-related, triggered by a medication error incident report. The incident was substantiated with one deficiency cited and a technical violation issued.
Findings
The investigation found that on 09/07/2023, a staff member gave the resident two tablets instead of one for a prescribed medication. The licensee notified the prescribing physician and followed instructions, with no adverse health consequences to the resident. One deficiency and one technical violation were cited, and a plan of correction was developed.
Deficiencies (1)
The licensee did not assist 1 of 64 residents with self-administered medications as needed/prescribed, posing a potential health risk.
Report Facts
Deficiencies cited: 1
Technical Violations issued: 1
Resident count during visit: 64
Facility capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Austin Irwin | Executive Director | Met during visit and exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 120
Deficiencies: 2
Date: Aug 30, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 08/24/2023 alleging that the facility was not clean, did not have sufficient supplies, and was in disrepair.
Complaint Details
The complaint investigation was substantiated for allegations of uncleanliness and insufficient supplies, but unsubstantiated for the allegation of facility disrepair. The investigation included observations, staff interviews, and record reviews. The Executive Director and staff cooperated with the investigation and a plan of correction was developed.
Findings
The investigation substantiated that the facility was not clean and did not have sufficient supplies, posing potential health and personal rights risks to all 62 residents. The allegation that the facility was in disrepair was found to be unsubstantiated.
Deficiencies (2)
Facility was not kept clean, including sticky floors and unclean rooms and common areas in Memory Care.
Facility did not have sufficient supplies such as gloves, detergent, toilet paper, and paper towels.
Report Facts
Capacity: 120
Census: 62
Plan of Correction Due Date: Sep 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Austin Irwin | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings discussion |
| Esther Miller | Licensing Program Analyst | Conducted the complaint investigation visit |
| Denise Powell | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Capacity: 120
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an LIC624 Incident Report regarding a resident found outside the facility premises.
Findings
The facility staff responded appropriately to the incident involving Resident #1 who was found walking on the street curb. No deficiencies were cited, and no evidence showed that staff failed to provide needed care or follow the facility’s Elopement Plan.
Report Facts
Facility capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Giovanni Arguello | Memory Care Unit Director | Met with Licensing Program Analyst during the visit and participated in exit interview |
| Riza Gloria Alvarez | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Plan of Correction
Census: 62
Capacity: 120
Deficiencies: 1
Date: Jul 6, 2023
Visit Reason
The visit was an unannounced Plan of Correction (POC) inspection to confirm that a previously issued citation from 04/28/2023 had been corrected.
Findings
The inspection found that the signal devices in the memory care unit were operational and satisfactory, meeting the POC deadline. No new deficiencies were identified during the visit.
Deficiencies (1)
Signal devices in the memory care unit were inspected and found operational and satisfactory.
Report Facts
Facility capacity: 120
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Giovanni Arguello | Resident Services Coordinator | Met with LPA during the inspection and participated in exit interview |
| Singh Wong | Maintenance Director | Met with LPA during the inspection |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection visit |
| Lizzette Tellez | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 120
Deficiencies: 5
Date: Apr 28, 2023
Visit Reason
The visit was an unannounced Case Management inspection conducted in response to an LIC624 Incident Report regarding a resident who was found outside the facility unassisted, posing a safety concern.
Complaint Details
The visit was triggered by a complaint incident report of a resident with dementia who was found outside the facility unassisted. The complaint was substantiated as staff failed to follow the absentee notification plan, delaying law enforcement involvement.
Findings
The inspection found that facility staff did not comply with the absentee notification plan, delaying law enforcement notification and potentially risking resident safety. Additionally, multiple deficiencies were cited related to unsecured exit doors, lack of required signage on delayed-egress doors, absence of signal systems in memory care units, and missing auditory devices to monitor exits.
Deficiencies (5)
Facility staff did not comply with the absentee notification plan for a missing resident, posing a potential safety risk.
Delayed-egress door gate lacked required signage as per California Health and Safety Code.
Multiple interior delayed-egress doors had signs that did not meet placement/position requirements.
Memory care living units lacked a signal system operating from each resident's living unit.
Facility lacked an auditory device or staff alert feature to monitor exits, posing a safety risk to a resident with dementia.
Report Facts
Residents present: 71
Total licensed capacity: 120
Deficiencies cited: 5
Residents affected: 24
Plan of Correction due date: May 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill McDonald | Executive Director | Facility representative interviewed and present during exit interview |
| Dang Nguyen | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lizzette Tellez | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 74
Capacity: 120
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
The visit was an unannounced Case Management visit conducted in response to an Unusual Incident/Injury Report for Resident #1 received on 2023-02-08.
Findings
The Licensing Program Analyst toured the facility, reviewed pertinent records, and did not observe any immediate health or safety concerns. No deficiencies were cited during this visit, but additional visits may be necessary.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill McDonald | Executive Director | Met with Licensing Program Analyst during the visit and participated in the exit interview. |
| Sabel Martinez | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Denise Powell | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Original Licensing
Census: 82
Capacity: 120
Deficiencies: 0
Date: Jul 5, 2022
Visit Reason
The inspection was a scheduled pre-licensing visit to observe the physical plant for compliance and to conduct a Component III as part of a change of ownership application.
Findings
The facility was found to be compliant with relevant statutes and regulations, including infection control practices, physical plant conditions, and safety measures. The facility is ready to be licensed pending management approval.
Report Facts
Licensed capacity: 120
Current residents: 82
Non-ambulatory residents allowed: 110
Bedridden residents allowed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carline Callaghan | Executive Director | Met during inspection and exit interview |
| Miguelito Uson | Maintenance Director | Met during inspection |
| Sabel Martinez | Licensing Program Analyst | Conducted the inspection |
| Denise Powell | Licensing Program Manager | Named in report |
Inspection Report
Original Licensing
Census: 81
Capacity: 120
Deficiencies: 0
Date: Apr 22, 2022
Visit Reason
The visit was conducted as part of the original licensing process for the facility, including verification of applicant and administrator qualifications and understanding of regulatory requirements.
Findings
The licensing process was successfully completed via telephone conference, confirming understanding of Title 22 regulations, facility operation, staff qualifications, program policies, and compliance requirements. No deficiencies or violations were noted in the report.
Report Facts
Capacity: 120
Census: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carline Callaghan | Administrator | Participated in licensing process and telephone conference |
| Julia Kim | Licensing Program Manager | Named in report as Licensing Program Manager |
| Thai Doan | Licensing Program Analyst | Named in report as Licensing Program Analyst |
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