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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 10/20/2021
Date Signed: 10/20/2021 09:13:32 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 SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 87DATE:
10/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Usman ChaudaryTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced case management visit to obtain signatures on an amended complaint investigation report. LPA met with Director of Memory Care Usman Chaudary and spoke with Eva Tawfik via telephone. LPA discussed amended report and obtained required signature.

An exit interview was conducted where this report was discussed and provided to Mr. Chaudary
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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