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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005272
Report Date: 07/12/2022
Date Signed: 07/12/2022 04:28:38 PM


Document Has Been Signed on 07/12/2022 04:28 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: 36DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Stacie Anderson - Executive DirectorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Pacifica Senior Living South Coast. LPA Velazquez was allowed entry into the facility and met with Executive Director (ED) Stacie Anderson. The purpose of today's Case Management visit was in relation to Complaint 22-AS-20220531161434 and to review Title 22 Regulations Sections 87465 Incidental Medical and Dental Care, 87469 Advanced Directives and Requests Regarding Resuscitative Measures, 87466 Observation of the Resident, and 87211 Reporting Requirements. LPA also reviewed the LIC 624 Unusual Incident Report and proper completion of this report.


LPA Velazquez reviewed the aforementioned regulations with ED Stacie Anderson and provided copies of these regulations during the visit. ED Anderson acknowledged receiving copies of the aforementioned regulations. LPA Velazquez advised ED Anderson to conduct in-service training regarding these Title 22 regulations and submit documentation of said training to LPA Velazquez by August 1, 2022.


There were no deficiencies issued during this Case Management visit. An exit interview was conducted with Executive Director Stacie Anderson and a copy of this report was provided at the time of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022
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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