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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004640
Report Date: 06/24/2022
Date Signed: 06/24/2022 11:45:56 AM


Document Has Been Signed on 06/24/2022 11:45 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: 21DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Rosie NakadairaTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Executive Director Rose Nakadaira and stated the purpose of this visit.

The facility is a two-level structure split into two cottages licensed for forty non-ambulatory of which fifteen may be bedridden and a hospice waiver for fifteen. This facility offers Residential Care for the Elderly.

At about 9:10 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA Tapia reviewed Facility Personnel Report and noticed that staff (cook) Dolorez Franco De Olvera was not associated with the facility. LPA Tapia was shown proof that LIC 9182 and a copy of California ID were sent for association. Administrator also provided LIC 500 and individual is on the current roster. Administrator was informed that all staff need to be associated to the facility. LPA toured the interior and exterior portions of the facility. Resident rooms were selected at random for inspection. In cottage one bedrooms (1,2,3) were selected for inspection. In cottage 2 resident rooms (22,15) were inspected for selection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did not have private restrooms. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 114.0 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 121.6 degrees Fahrenheit. Administrator was made aware of water temperature regulations. LPA did not notice handing washing signs in the common restrooms. LPA Tapia did not notice PUB 475 poster posted in a prominently location. LPA Tapia, informed Executive Director that PUB 475 needs to be posted at all times.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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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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: 06/24/2022
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 Executive Director did provide proof of annual inspections for fire alarms. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. LPA Tapia noticed while reviewing canned foods in the kitchen some were expired. Administrator was made aware of this finding and removed canned food immediately. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. The second floor of the facility is used a storage unit as well as a breakroom for staff. Residents do not have access to the second floor of the facility.

Kitchen was in good repair with knifes and cleaning supplies kept locked. Kitchen is also in a separate room and is kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.



For this visit, No deficiency was noted in areas observed. No citation was issued. Five advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Rose Nakadaria and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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