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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001848
Report Date: 05/27/2022
Date Signed: 05/27/2022 12:57:07 PM


Document Has Been Signed on 05/27/2022 12:57 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, 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: 84DATE:
05/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edward Maslobodsky - AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Pacifica Royale Assisted Living Community. LPA Velazquez was allowed entry into the facility and met with Administrator Edward Maslobodsky. The purpose of today's Case Management visit was to follow-up on an Incident Report received in the Orange Regional Office on May 20, 2022 regarding Resident (R) #1.



On today's visit LPA Velazquez conducted an interview with Administrator Maslobodsky. Per Administrator R1 has yet to return to the facility. LPA Velazquez reviewed R1's file and requested copies of pertinent documentation from R1's file. LPA also requested a copy of the police report when it becomes available. LPA and Administrator also conducted a tour of R1's room.





There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Administrator Edward Maslobodsky and a copy of this report along with the LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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