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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005272
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:13:15 PM


Document Has Been Signed on 07/03/2024 01:13 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
CCLD Regional Office, 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: 35DATE:
07/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stacie Anderson TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced health and safety case management visit in conjunction with an SOC 341 received by the department on 06/24/2024. LPA was greeted and granted entry by Administrator Stacie Anderson and explained the reason for the visit.

During the visit, LPA toured the facility and observed the following: Facility is clean and sanitary and consists of two floors housing assisted living and memory care units. There are 35 residents present during today's visit. Facility has ample food in supply and LPA observed residents dining. LPA toured the memory care unit and observed residents relaxing in the dining room. LPA spoke with residents who expressed satisfaction with facility and verbalized being safe in the facility.

LPA reviewed and obtained records for Resident 1 including physician report, pre-appraisal and medication orders.



LPA observed no health or safety concerns during today's visit.



Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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