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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425691
Report Date: 12/29/2021
Date Signed: 01/18/2022 09:22:15 AM

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 LIVING CENTERFACILITY NUMBER:
336425691
ADMINISTRATOR:LUZ, PRICEFACILITY TYPE:
740
ADDRESS:41130 DENIAN COURTTELEPHONE:
(951) 600-8888
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 5DATE:
12/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Luz Price, AdministratorTIME COMPLETED:
02:10 PM
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Prior to conducting the visit, LPA completed the covid-19 risk assessment. Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry by Administrator Luz Price. LPA met with Administrator and explained the purpose of the visit. At the time of visit there were 3 staff and 5 residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The hand washing signs were removed due to maintenance work being completed, and will be replaced per Administrator. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer). Staff were also observed wearing appropriate face coverings (surgical masks).

The facility has a mitigation plan that was submitted 04/16/21, that is posted on the cork board in the entry way for all to review. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks once a day. A technical advisory was issued as the temperature checks are not being documented, Administrator agreed to begin on 12/30/21. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. All facility staff on shift are responsible for cleaning and disinfecting the highly touched surfaces as needed throughout each shift.
Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to Administrator Luz Price.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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