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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425691
Report Date: 01/25/2023
Date Signed: 01/30/2023 10:23:19 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/30/2023 10:23 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, 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:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, LuzTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit on 1/25/2023 at 2:00 p.m. in order to conduct an annual visit with a focus on infection control. LPA met with Administrator Luz Price, who was informed of the purpose of the visit. At the time of the visit there were (2) staff and (5) residents present. LPA reviewed the administrator;s certificate and found it was current. LPA conduct a tour of the facility's interior and exterior and observed the, central entry point, sign in sheet where screenings are done for facility visits. LPA observed the facility's PPE supplies and found that the facility did not meet the 30-day supply that is required. Technical advisory note was documented.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where this report was reviewed and provided to Administrator, Luz Price..
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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