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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 07/30/2024
Date Signed: 07/30/2024 03:24:31 PM


Document Has Been Signed on 07/30/2024 03:24 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:CASTRO, GILBERT MFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:90CENSUS: 46DATE:
07/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Gendelle Camarillo/Glenda BertucciTIME COMPLETED:
03:45 PM
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On this day at around 2:20 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived at the facility to conduct a case management visit related to an incident reported by the facility. LPA met with Gendelle Camarillo, Resident Services Director. Executive Director (ED) Glenda Bertucci arrived at around 3pm. .
On July 14, 2024, a stranger came to the facility and dropped off R1. R1 was found at the Safeway Supermarket on Washington Ave. which is 0.3 miles from the facility. R1's Physician's Report indicates R1 has Mild Cognitive Impairment (MCI) and is not able to leave the facility unattended.

Based on interview with RSD, R1 was not harmed from the incident. RSD added that staff training was conducted and R1 has been reassessed by R1's doctor. Pending the release of R1's updated Physician's Report, the facility has plans in place to ensure R1's safety while at the facility. If R1 is diagnosed with Dementia, R1 will need to be moved out of the facility because the facility does not have a dementia program.

A technical violation advisory was issued during the visit.

A copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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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