374603714-6-16-2026-08-AS-AGOH-DV4US9-20260616154958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603714
Report Date: 06/16/2026
Date Signed: 06/16/2026 03:50:05 PM

Document Has Been Signed on 06/16/2026 03:50 PM - 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:	ACTIVCARE AT 4S RANCH		FACILITY NUMBER:	374603714
ADMINISTRATOR/ DIRECTOR:	DENISE NOTTER		FACILITY TYPE:	740
ADDRESS:	10603 RANCHO BERNARDO ROAD		TELEPHONE:	(858) 485-8001
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY: 60		CENSUS: 48	DATE:	06/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Front Desk Staff Ahdiyeh Dargahi and Executive Director Denise Notter		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Front Desk staff Ahdiyeh Dargahi and Executive Director Denise Notter. Note, LPA did step out for lunch from 12-1pm. The facility's license shows a maximum capacity of sixty (60) non-ambulatory residents, fifteen (15) of which may be bedridden. Additionally, the facility is approved for delayed egress and a secured perimeter, as well as a hospice waiver for twenty (20). During today’s inspection there were forty-eight (48) residents in care, with one (1) bedridden, and fifteen (15) currently receiving hospice services. LPA and Executive Director Notter toured the interior and exterior of the facility and inspected common areas and a sample of occupied and non-occupied resident units. During LPA's visit, the facility happened to be in the process of having their carpets replaced. Per Executive Director Notter, the first half was completed yesterday and the remainder was to be conducted today. LPA observed a number of staff monitoring residents indoors and outdoors to redirect them from the work areas. LPA observed a staff member posted at one of the exit doors where workers would bring materials in and out of, to ensure no residents slipped out. LPA additionally observed staff engaged with residents in a variety of activities such as painting, puzzles, and other game activities. [Continued on LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ACTIVCARE AT 4S RANCH	FACILITY NUMBER: 374603714
	VISIT DATE: 06/16/2026

NARRATIVE

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[Continued from LIC 809]

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms inspected contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: one sample unit bathroom sink was 117F and one resident unit bathroom on the other side of the building read at 116.8F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. As the kitchen access door was behind a locked door, knives were inaccessible to any residents in care

No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. While no pools are present on the premises, the front entry way does feature a fountain, however it is not accessible to any residents. Per Executive Director Notter, no firearms or ammunition are kept at the facility. Facility Fire Panel was in operational order, along with emergency lighting and facility telephone. Fire extinguishers were serviced within the last 12 months, dated for August 2025, though they are also inspected monthly by facility maintenance staff. Last staff emergency drill conducted was 6/1/26 for the topics of fire and disaster scenario of a car driving into the building. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed two (2) staff and two (2) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

No deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Notter to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC809 (FAS) - (06/04)

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