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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:09:17 PM


Document Has Been Signed on 11/06/2023 03:09 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,
, CA



FACILITY NAME:PACIFICA SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 86DATE:
11/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Eva Tawfik, Executive Director TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management visit to the facility. The purpose of the visit was to review and obtain copies of documentation pertaining to an open complaint for the facility. LPA met with Eva Tawfik and explained the purpose of the visit. In addition LPA conducted interviews with staff.

No health and safety concerns were observed at the time LPAs visit.

An exit interview was conducted and a copy of this report was provided to Eva Tawfik, Executive Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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