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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001848
Report Date: 04/13/2024
Date Signed: 04/13/2024 11:27:04 AM


Document Has Been Signed on 04/13/2024 11:27 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: 91DATE:
04/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Facility Administrator - Edward MaslobodskyTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection. LPA De Perio was greeted by staff on duty, who notified facility administrator (AD) Edward Maslobodsky about visit. The PUB475 "See Something, Say Something" poster was observed to be posted at the entrance of the facility. LPA observed the Administrator's Certificate for Edward Maslobodsky, which expires on 5/15/2025, and is posted at the front entrance of the facility.

LPA De Perio toured the interior and exterior portions of the facility with AD Maslobodsky. Facility is a three level structure and is licensed for 132 residents, of which 3 may be on hospice and 0 may be bedridden. LPA De Perio toured a total of 9 random resident bedrooms of which, bedrooms observed were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. Most recent fire inspection took place on 3/6/2024. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 106.4 degrees Fahrenheit. LPA De Perio also tested pull cords in random resident rooms, and observed for it to be operational.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility. LPA De Perio tested delayed egress doors and observed for it to be operational. LPA De Perio also observed evacuation chairs in stairwells. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at at the front desk of the facility. Facility had back-up emergency food and water supply, located in the kitchen and in multiple storage areas around the kitchen.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 306001848
VISIT DATE: 04/13/2024
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LPA De Perio observed that First Aid Kit had all the required components. Medications were locked, and made in accessible to residents in care, and is located in the medication room. Toxins were also observed to be locked and inaccessible to residents.

For this visit, no citations were issued.

LPA De Perio conducted an exit interview with AD Maslobodsky.

A copy of this report was provided and explained to the facility.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2024
LIC809 (FAS) - (06/04)
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