Inspection Reports for
Rancho Penasquitos Senior Living

The licensee failed to correct the deficiency and notify the Licensing Program Analyst by the due date, resulting in a civil penalty of $100 per day assessed from 1/6/26 to 1/8/26 totaling $300. The POC was eventually submitted and cleared on 1/8/26.

The visit was triggered by three self-submitted incident reports involving Resident #1: an altercation with another resident on 12/09/2025, an unwitnessed fall on 12/11/2025 requiring hospitalization, and the resident's death on 12/17/2025. The complaint investigation included interviews and record reviews.

One deficiency was cited related to a staff member lacking a required Criminal Background Clearance, posing an immediate safety risk to all residents. An immediate civil penalty of $500 was assessed and a Plan of Correction was jointly formed with the Licensee.

The visit was complaint-related, triggered by an incident report received on 12/22/25 regarding a resident who fell down a stairwell on 12/8/25. The deficiency cited relates to late submission of the incident report.

The facility responded by conducting room checks and a search, arranging prompt medical attention for R1. One Type B deficiency was cited for failure to submit a written incident report to the Department within the required seven-day timeframe.

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.

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 investigation included interviews with staff, hospice, and review of records. The facility did not obtain a hospice care plan for Resident #1 and did not follow hospice recommendations fully. Concerns were raised about delays in responding to incontinence care calls and linen availability.

The investigation substantiated the allegations that Resident #1 experienced neglect leading to pressure injuries, staff did not adequately meet incontinence needs, and residents were not consistently provided with clean linens. Deficiencies were cited and plans of correction were formulated with the facility's Executive Director.

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.

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.

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 a complaint regarding a medication error where Resident #1 was given an extra dose of medication in the evening instead of the morning. Emergency medical services and Poison Control were consulted and determined no further medical aid was needed. The resident's responsible party was notified.

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.

The visit was triggered by an incident report received on 03/10/2025 regarding a resident who washed their face with Ajax cleaning solution left in their bathroom, resulting in irritation and redness. The resident received urgent care treatment and has follow-up appointments scheduled.

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 facility submitted a plan of correction to provide hazardous materials storage/procedures training for housekeeping staff.

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 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 alleged staff did not treat a resident with dignity by placing a hand over the resident's mouth and telling them to be quiet. The allegation was substantiated based on staff admission and investigation.

The investigation substantiated that Staff #1 placed their hand over a resident's mouth and told them to be quiet, violating company policy and resident dignity rights. In-service training was conducted for all staff after the incident.

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 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 self-submitted LIC624 Incident Report about a medication error. The complaint was substantiated as the medication error occurred but did not cause injury or illness.

The investigation found that Staff #1 gave Resident #1 two tablets instead of one as prescribed, but the error did not result in any adverse health consequences. One deficiency was cited for failure to assist a resident with self-administered medications as needed, and one Technical Violation was issued regarding reporting requirements. A Plan of Correction was developed and corrective actions were taken.

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 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 that the facility was not clean and did not have sufficient supplies. The allegation that the facility was in disrepair was unsubstantiated.

The allegations that the facility was not clean and did not have sufficient supplies were substantiated based on observations of sticky floors, unclean resident rooms, lack of paper towels, and insufficient supplies of hand soap and detergent. The allegation that the facility was in disrepair, specifically regarding the dishwasher and kitchen sinks, was found to be unsubstantiated.

The signal devices in the memory care unit were inspected and tested, found to be operational and satisfactory. No new deficiencies were identified or cited during the visit.

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 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 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 complaint-related, triggered by an incident report of a resident found outside the facility unassisted. The complaint was substantiated as the facility failed to follow its absentee notification plan and safety protocols.

The facility failed to follow its absentee notification plan during the incident, delaying law enforcement notification. Multiple deficiencies were found including lack of required signage on delayed-egress doors, absence of signal systems in memory care living units, and missing auditory devices on exit doors, all posing potential safety risks to residents.