Inspection Reports for Rancho Penasquitos Senior Living

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced continuation annual inspection conducted by the Licensing Program Analyst to assess compliance with licensing requirements.

The inspection included interviews and record reviews, and no deficiencies were cited during this visit.

The inspection was an unannounced required annual inspection visit conducted to evaluate the facility's compliance with licensing regulations.

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.

Licensing Program Analyst Amy Rodgers conducted an unannounced required one-year inspection to ensure substantial compliance with Title 22 regulations at the facility.

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.

The visit was conducted in response to an LIC624 Incident Report self-submitted by the licensee involving Resident #1 on 2023-11-06.

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.

The visit was triggered by a complaint incident report involving Resident #1, with no deficiencies found and the resident verified to be safe.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced Case Management visit conducted in response to an LIC624 Incident Report regarding a resident found outside the facility premises.

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.

The visit was an unannounced Plan of Correction (POC) inspection to confirm that a previously issued citation from 04/28/2023 had been corrected.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.