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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005272
Report Date: 06/12/2024
Date Signed: 06/12/2024 05:46:50 PM


Document Has Been Signed on 06/12/2024 05:46 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 SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 34DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stacie AndersonTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with the Executive Director (Administrator) Stacie Anderson and explained the reason for the visit. The Administrator's certificate expires on October 15, 2025. LPA and the Executive Director toured the facility. LPA observed the see something say something poster posted in the lobby of the facility. The facility is a 2 story building with a secured memory care unit on the first floor. LPA observed all the memory care delayed egress exits are operational. LPA and the Executive Director toured the kitchen and dining room. The kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the refrigerator and freezer were operational. LPA measured the hot water in 5 resident rooms, hot water measured between 110.0 degrees Fahrenheit to 115.0 degrees Fahrenheit. LPA observed all resident rooms inspected had the required furnishings and bedding. LPA observed all resident bathrooms checked were clean and operational. LPA observed cleaning supplies are kept locked in a storage closet. LPA and the Executive Director toured the second floor. LPA observed the call system is operational. LPA observed the call response time is less than 5 minutes. LPA observed emergency evacuation chairs at each stairwell. LPA observed there is outdoor shaded seating areas for memory care and assisted living. No bodies of water in the outdoor areas of the facility. LPA reviewed the fire alarm system paperwork showing the system passed its annual inspection on February 8, 2024. LPA reviewed 5 resident files, no discrepancies observed. LPA reviewed 5 resident's medications, no discrepancies observed. LPA observed the medication is kept locked in the Med Room. LPA observed the first aid kit did not have a current edition manual. LPA interviewed staff and residents. LPA reviewed 5 staff files. 2 of the staff files were for caregivers. LPA observed that 3 out of 5 staff files had no health screening. LPA observed that 2 out of 2 of the caregiver files did not have current training. The staff interviewed reported having in service training and online training. The Executive Director reported that staff are trained, but at this time there is no way to verify the training. No other discrepancies observed. Violations are being per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/12/2024 05:46 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 SOUTH COAST
FACILITY NUMBER: 306005272

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee agrees to have staff with no health screening, to be screened by a physician and to provide the Health screening form (LIC 503) on file for each staff member. Proof to be forwarded to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 caregiver files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2024
Plan of Correction
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Licensee agrees to have all training documented for caregivers and to provide proof of training for caregivers LPA by the POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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