<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:18:46 PM


Document Has Been Signed on 10/01/2024 02:18 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: 56DATE:
10/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Marissa Baldomero, Resident Services Director TIME COMPLETED:
02:30 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
On this day at around 2:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an 30-day termination notice of R1. LPA met with Resident Services Director, Marissa Baldomero and explained the purpose of the visit.

LPA received an 30day termination notice in regrade of R1 not being able to pay. R1 is still reside at the facility. S1 stated R1 have not pay the facility since February 2024. The letter indicated that the notice effective date is June 14, 2024, due to the outstanding amount of 7,321.67. S1 stated that R1 family is aware of the situation, and family didn’t say anything. R1 is not reserved, no POA, and R1 makes own decision, and R1 is the full payee. Facility is in the process of eviction but is waiting for the judge to make the final decision. S1 stated R1 told them R1 knows that R1 owe money but doesn’t want to pay, and is waiting to be evicted.

No deficiency was noted during the visit.

A copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1