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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 06/05/2024
Date Signed: 06/05/2024 12:49:08 PM

Document Has Been Signed on 06/05/2024 12:49 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR/
DIRECTOR:
MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 82DATE:
06/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Mark Pacia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility regarding the department receiving an SIR of an incident that took place on June 2, 2024 of medications that were taken during a robbery. LPA spoke with Administrator Mark Pacia and obtained additional information. LPA toured the area accompanied by the Administrator. LPA conducted a health, safety and welfare check of residents in care and Administrator confirmed that no residents were identified that were victimized, injured or harmed during the incident. Administrator confirmed the staff that were present and victimized have been offered resources by the facility. LPA received an inventory of medications that were taken. Administrator confirmed the medications that were taken have been replaced and no resident had a lapsed in receiving their medications on time. Administrator confirmed that emails and letters were sent to resident's family or responsible parties regarding the incident. Administrator confirmed that the police were notified and investigation is on going. Administrator confirmed with LPA that preventative measures are going to be implemented for the safety of all residents, staff and visitors.

There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22.

An exit interview was conducted, a copy of this report were provided to the Executive Director, Marc Pacia.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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