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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:15:36 PM


Document Has Been Signed on 07/13/2023 04:15 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 OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:GARCIA, ANTHONYFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:197CENSUS: 102DATE:
07/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Anthny Garcia, AdministratorTIME COMPLETED:
04:20 PM
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On 7/13/23 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 118.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/26/23. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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