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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004640
Report Date: 06/25/2021
Date Signed: 10/05/2021 11:15:41 AM

Document Has Been Signed on 10/05/2021 11:15 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACIFICA SENIOR LIVING NEWPORT MESAFACILITY NUMBER:
306004640
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2891 BEAR STTELEPHONE:
(949) 629-1020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 40CENSUS: 19DATE:
06/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Business Office Manager Rose Nakadaira.TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit to Pacifica Senior Living. The purpose of today’s visit was to conduct the Required 1 year inspection. LPA was allowed entry into the facility and met with Business Office Manager Rose Nakadaira. Facility is licensed for 40 non-ambulatory residents of which 15 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 19 residents. The facility specializes in Dementia. There are 4 residents on Hospice Care during today's visit. Executive Director Stacie Anderson has an administrator certificate is current.
LPA Frank along with Business Office Manager Rose Nakadaira toured the facility. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility. LPA observed all staff wearing PPE.
LPA toured the physical plant, checked food service, and the first aid kit. The facility consists of two separate buildings named Winter and Summer. The Winter building has 11 resident rooms and 4 resident bathrooms and Summer building has 12 resident rooms and 4 resident bathrooms. There are no private bathrooms in the facility. Upon entry into the Winter building, LPA toured four resident rooms. LPA tested four resident call buttons and four out of four call buttons were operable. All four resident rooms had locked closets with resident's personal items inaccessible. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.3 and 112.5 in facility bathrooms. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. The main kitchen as well as the auxiliary Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed cleaning supplies locked in a cabinet under the sink. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PACIFICA SENIOR LIVING NEWPORT MESA
FACILITY NUMBER: 306004640
VISIT DATE: 06/25/2021
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LPA observed documentation of fire safety inspection and sprinkler testing dated 02/2021. LPA toured the outside grounds and observed seating areas for residents. Outside grounds are an enclosed circle allowing residents to roam freely throughout the grounds. Facility has a delayed egress system on the single exit gate. LPA observed the activity schedule as well as observed residents participating in activities. LPA reviewed four resident files as well as six staff files. All resident files contained required documentation including current physician reports. All staff files reviewed contain documentation of a health screening/ TB test, proof of required annual training as well as fingerprint clearance. LPA observed medication storage and Current medications are kept in a locked medication cart and overflow medications are stored in locked cabinets in the medication room.

LPA reviewed current LIC 308, Designation of Facility Responsibility, LIC 500, Personnel Report, LIC 610, Emergency Disaster Plan, Administrator's Certificate is current, liability insurance expires on 12/31/2021.

Based on this inspection, no deficiencies were observed at this time in the areas evaluated.
This report was discussed with the facility representative and a copy of this report was left at the facility.

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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