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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 10/20/2020
Date Signed: 10/20/2020 01:19:19 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 UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
10/20/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joyce Latimer/Amelia CamatTIME COMPLETED:
12:00 PM
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On this day at around 11 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management televisit in connection with a fall incident reported to CCL on 10/13/2020. LPA explained to Executive Director that this televisit is being conducted via Zoom in connection with the shelter in place order by the governor and telework directive by management.

LPA met with Executive Director (ED) Joyce Latimer and Resident Services Director (RSD) Amelia Camat. LPA requested RSD to show to LPA and take a picture of R1's window where he fell. LPA observed no screen window installed during the televisit. LPA interviewed ED and RSD about the incident when R1 was found on the ground with only underwear on.

LPA received the following records from the facility: Physician's Report, Needs and Services Plan, Mini Mental Test, covid test result and assessment. LPA requested the following records during the televisit:
Lic 500 specifically for October 12 and 13, staff 3 and staff 4 contact information.

Also, LPA interviewed R1's responsible person who states that R1 is still in the hospital. Responsible person will call back LPA for additional information and updates.

LPA advised ED that more interviews will be conducted and will have to schedule another televisit in the future.

A copy of this report was provided to Executive Director via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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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