<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:28:53 PM

Document Has Been Signed on 11/18/2024 12:28 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, 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: 93DATE:
11/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Barbara Bogoje, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED.

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, Barbara Bogoje.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 1