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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001848
Report Date: 12/15/2021
Date Signed: 12/15/2021 04:12:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFICA ROYALE ASSISTED LIVING COMMUNITYFACILITY NUMBER:
306001848
ADMINISTRATOR:EDWARD MASLOBODSKYFACILITY TYPE:
740
ADDRESS:15022 PACIFIC ST.TELEPHONE:
(714) 892-4446
CITY:MIDWAY CITYSTATE: CAZIP CODE:
92655
CAPACITY:132CENSUS: 83DATE:
12/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Edward MaslobodskyTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management visit to follow up on an Incident report submitted to Community Care Licensing on 12/14/2021. LPA Martinez was greeted and granted entry into the facility by Administrator Edward Maslobodsky and explained the reason for the visit.

Incident report dated 12/14/2021 indicated that Resident 1 (R1) complained of lower back pain and it was getting uncomfortable. R1 requested to go to the hospital and was transported to Huntington Beach Hospital for evaluation. AD received a call from the hospital that R1 will be transferred to UCI Medical Center and told AD that R1 had fallen at the facility. AD stated he told hospital staff that R1 never reported the fall and only reported to having lower back pain, therefore Lynch Ambulance was called to transport.

LPA Martinez toured R1's room and did not observe any health and safety concerns in the room. Per Physician's Report dated 03/20/2018, R1 is diagnosed with Schizophrenia. R1 was admitted into the facility on 12/8/2015.

No deficiency cited during this review as per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with AD Maslobodsky and a copy of this report will be emailed.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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