306005272-5-13-2022-22-AS-PVEZ-CEDPBY-20220513111108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005272
Report Date: 05/13/2022
Date Signed: 05/13/2022 11:11:14 AM

Document Has Been Signed on 05/13/2022 11:11 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 SOUTH COAST		FACILITY NUMBER:	306005272
ADMINISTRATOR:	STACIE ANDERSON		FACILITY TYPE:	740
ADDRESS:	2619 ORANGE AVE		TELEPHONE:	(949) 515-0121
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	98	CENSUS: 35	DATE:	05/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Stacie Anderson - Executive Director		TIME COMPLETED:	11:25 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Pacifica Senior Living South Coast. The purpose of today's visit was to conduct a Required 1 Year inspection focusing on Infection Control. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Stacie Anderson. The facility is licensed for 98 non-ambulatory residents of which 20 residents may be bedridden. The facility also has a hospice waiver for 20 residents. LPA was provided with a copy of last year's Fire inspection which was conducted on April 13, 2021. ED Anderson informed LPA Velazquez that a Fire inspection was conducted on March 23, 2022. LPA was also provided with a copy of the most recent liability insurance. The last emergency disaster drill was conducted on February 25, 2022. At 9:16 AM LPA Velazquez conducted a tour of the physical plant along with ED Anderson. The facility consists of 2 stories with 55 resident rooms each with their own or shared bathrooms. There are 3 activity rooms, a movie theater, 2 dining rooms, kitchen, a hair salon, memory care area, a library/game room, 3 courtyards, and a lobby area. LPA Velazquez did not observe the Complaint poster in the facility which ED Anderson verified. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface was in place. LPA Velazquez tested the hot water temperature in 10 resident bathrooms and the temperature ranged from 69.4 degrees Fahrenheit to 134.4 degrees Fahrenheit verified by ED Anderson. ED Anderson proceeded to inform the facility's maintenance director so they could address the water temperature. LPA Velazquez tested the pull cord signal system and facility staff responded to the pull cords within 3 minutes. LPA Velazquez inspected the kitchen along with ED Anderson. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. Emergency food supply was also adequately

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

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 SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 05/13/2022

NARRATIVE

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stocked. Fire Extinguishers throughout the facility were fully charged. Toxins, sharps, and medications were locked and inaccessible to residents in the Memory Care area of the facility. The delayed egress doors were tested and found operational.

LPA Velazquez along with ED Anderson toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Executive Director Stacie Anderson and a copy of this report along with the appeal rights and a copy of the LIC 9098 and LIC 9102 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/13/2022 11:11 AM - 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
CCLD Regional Office, 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: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 10 bathrooms where the hot water temperature exceed 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water temperature is maintained pursuant to regulation and submit written proof to LPA by POC due date.

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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022

LIC809 (FAS) - (06/04)

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