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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 10/20/2020
Date Signed: 10/27/2020 11:48:25 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 HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:TAYLOR, MANDYFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 121DATE:
10/20/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Mandy Taylor, Executive DirectorTIME COMPLETED:
02:51 PM
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to conduct an unannounced health and safety tele-inspection to address concerns relating to complaint # 18-AS-20200731095043. The LPA identified herself and discussed the purpose of the call with Executive Director (ED), Mandy Taylor. The LPA conducted resident interviews; no reports of concerns relating to neglect or care and supervision were received. No health and safety concerns were observed at time of visit.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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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