Inspection Report Summary for Rancho Penasquitos Senior Living

The California Department of Social Services Community Care Licensing Division reviewed Pacifica Senior Rancho Penasquitos (facility number 374604542) on four occasions between April 2022 and April 2023. An initial Component II visit on 22 April 2022 confirmed that the facility met the basic licensing requirements for a 740 residential care facility. The Administrator, Carline Callaghan, verified her identity, the licensing structure, staff qualifications, and the facility’s policies on abuse, medication management, and grievances. No deficiencies were noted, and the analyst advised the Administrator to submit the signed LIC 809 form.

On 5 July 2022, a pre‑licensing inspection, part of a change‑of‑ownership application, examined the physical plant and infection‑control protocols. The site was deemed ready for licensing, with no immediate health or safety concerns reported. The facility had an adequate food supply, locked medication and cleaning supplies, functional carbon monoxide detectors, and complied with the fire clearance granted on 10 February 2022.

Two case‑management visits followed, both unannounced and prompted by resident‑related incidents. On 14 February 2023, an unusual incident involving Resident #1 (R1) was reviewed. The analyst found no immediate health or safety concerns and cited no deficiencies, though additional follow‑up was suggested. The report indicated that R1 had dementia and was considered unsafe to leave the facility unassisted.

A subsequent visit on 28 April 2023 addressed a more serious AWOL event involving the same resident. The analyst noted that R1, after leaving the bedroom and being found outside the building, was not found until 6:06 AM and that law enforcement was not called within the 30‑minute window required by the facility’s absentee notification policy. The investigation also revealed two unlocked perimeter exit doors without auditory or staff‑alert devices, and a main lobby door that remained unlocked after hours. Following the incident, R1 was moved to a secured memory‑care section.

These reports collectively portray a facility that has met baseline licensing and infection‑control standards but has experienced lapses in emergency response and physical‑plant security during resident‑related incidents. The repeated involvement of a dementia‑afflicted resident highlights the need for robust protocols to prevent unauthorized exits and to ensure timely engagement of law enforcement when a resident’s safety is compromised.

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