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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 05/18/2021
Date Signed: 05/18/2021 11:19:20 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: 118DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Mandy TaylorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Pauline Beschorner arrived at the facility on May 18, 2021 at 9:57 AM to conduct an Annual/Required Visit. Upon LPA arrival, LPA's temperature was checked at the front desk and LPA signed a COVID questionnaire. LPA met with Executive Director Mandy Taylor. Taylor accompanied LPA on a tour of the inside and outside of the facility and the following was observed:

All staff are wearing a surgical mask while working at the facility. LPA observed the dining area to be blocked off and prepared for lunch. LPA observed 2 chairs at each table and Taylor told LPA that all residents are able to eat in the dining area at this time. When a resident has been diagnosed with COVID a tray of food is taken to the residents room by a caregiver on foam/Styrofoam and placed in the residents kitchen area.

LPA observed the outside entertainment area to have table and chairs with umbrellas for protection of the residents. Taylor stated that only vaccinated residents can sit at one table without masks however, if a resident has not been vaccinated the table must wear masks. All entertainment is being provided outside at this time.

LPA spoke with the Health Services Director Gabrielle Rossi who stated that she oversees the Med-Room audits all training for all staff in-services and residents as need, and confirms that infection control of the facility is being completed one time/shift.

LPA observed the facility has at least a 30-day supply of PPE and all infection control procedures are being followed. An exit interview was conducted and a copy of this report was provided to Executive Director Mandy Taylor. No citations or technical violations are being issued at this time.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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