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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:44:55 PM


Document Has Been Signed on 12/06/2023 04:44 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 UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:ROBY, ROBERT BFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 63DATE:
12/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Robert RobyTIME COMPLETED:
05:00 PM
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On this day at around 3:05 pm, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a case management visit in connection with an incident reported by the facility. LPA met with Executive Director Robert Roby and explained the purpose of the visit.

During the visit, LPA obtained Resident 1 (R1) Physician's Reports, Needs and Services Plan and Hospital discharge papers . LPA reviewed records and interviewed Staff 2 (S2) and Resident 1 (R1).

Based on R1's Physician's Report (PR) dated 9/22/2022, R1 is able to bathe/dress and feed self and is able to transfer to and from bed. Resident assessment dated 10/6/2022 indicates R1 ambulates independently with or without assistive device.

S2 states R1 ambulates independently. In a previous interview conducted with Memory Care Director, Director states R1 ambulates independently.

No deficiency was noted during the visit.

A copy of this report was provided to Roby.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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