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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001848
Report Date: 04/10/2024
Date Signed: 04/10/2024 10:10:09 AM


Document Has Been Signed on 04/10/2024 10:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 65DATE:
04/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Staff on Duty - Ludmila Pogosyan TIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management to the facility to follow up on a incident report received dated for 4/4/24. LPA explained reason for visit and was greeted by staff on duty (S1) Ludmila Pogosyan. Facility administrator (AD) Edward Maslobodsky was unable to be present during time of visit.

Per resident (R1) physician report, R1 does not have mild cognitive impairment/dementia, is able to leave the facility unassisted, and is responsible for self.

It was observed that the facility reported the incident to the department, police and R1's family.

For this visit, no health and safety concerns were noted.

No citations issued.

A copy of this report was provided and explained to S1.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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