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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 08/10/2020
Date Signed: 08/10/2020 12:57:53 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 OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:AMANDA M DOMINGUEZ NORTHFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:197CENSUS: 122DATE:
08/10/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Santoshi Dhakar, Resident Services DirectorTIME COMPLETED:
12:45 PM
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On 08/10/2020 at 12:15 PM, Licensing Program Analyst (LPA) D Panlilio conducted a Facetime Health and Safety check via tele-visit with Resident Services Director (RSD) Santoshi Dhakar as a result of the department receiving a priority 1 complaint during the COVID 19 shelter in place order.

During the health and safety check, LPA observed a total of 16 residents comfortably watching and following the stretching exercises by the activities staff in the Memory care recreation room. LPA toured facility with Licensee, 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 the health and safety check.

Due to COVID 19 shelter in place, RSD was not physically available to sign this report.

Exit interview conducted and a copy of this report provided to RSD.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020
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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