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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 02/24/2021
Date Signed: 02/25/2021 08:11:08 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: 101DATE:
02/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Mandy Taylor, Executive DirectorTIME COMPLETED:
09:17 AM
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone, due to COVID-19, for the purpose of amending the report issued on 02/19/2021 for complaint #18-AS-20200728152434. The LPA spoke with Executive Director (ED), Mandy Taylor and informed her of the purpose of the call.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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