306004640-8-22-2024-22-AS-BALN-D8DQQY-20240822122306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004640
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:23:16 PM

Document Has Been Signed on 08/22/2024 12:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFICA SENIOR LIVING NEWPORT MESA		FACILITY NUMBER:	306004640
ADMINISTRATOR:	STACIE ANDERSON		FACILITY TYPE:	740
ADDRESS:	2891 BEAR ST		TELEPHONE:	(949) 629-1020
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	40	CENSUS: 26	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Villalobos- Activity Director		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Liam Larson who greeted LPA and assisted with the tour of the facility. At 10:00 AM the Administrator Rose Nakadaira arrived at the facility and she was informed of the purpose of the visit.

Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature was tested throughout the facility which was within regulation 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins,and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. LPA also observed emergency food supply and water.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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 SENIOR LIVING NEWPORT MESA	FACILITY NUMBER: 306004640
	VISIT DATE: 08/22/2024

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Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians.

LPA also reviewed Three (3) staff files for First Aid/CPR certification, annual training's, health screenings and the files reviewed were not complete/current. Based on LPA's observations a citation was issued for not having the staff files current.

An exit interview was conducted, and this report was discussed and provided to Administrator Rose Nakadaira at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 12:23 PM - It Cannot Be Edited

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 SENIOR LIVING NEWPORT MESA	FACILITY NUMBER: 306004640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations,interview, and records reviewed, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to provide all staff members the annual required trainings and will provide LPA Allen proof of training and provide a written statement of understanding of cited regulations 87412 (a)- (h) signed by all staff members. Licensee has also agreed to update all staff files with the required First Aid/CPR certification, annual trainings, and health screenings.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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