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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 06/09/2020
Date Signed: 06/09/2020 12:33:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:BETH JENNINGS WILLIAMSFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:90CENSUS: 60DATE:
06/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Beth Jennings, Executive DirectorTIME COMPLETED:
11:30 AM
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On 06/09/2020 at 11:10am, Licensing Program Analyst (LPA) T. White called to conduct a health and safety check via tele-visit as a result of department receiving a priority 2 complaint.

During health and safety check, LPA observed a total of 5 staff members at facility.

LPA toured facility with Executive Director, Beth Jennings, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020
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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