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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600578
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:25:27 PM

Document Has Been Signed on 10/17/2022 12:25 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RANCHO PACIFICA HOMEFACILITY NUMBER:
374600578
ADMINISTRATOR:CHRISTINA GRUBBSFACILITY TYPE:
735
ADDRESS:1229 RANCHO PACIFICA PLACETELEPHONE:
(760) 758-9614
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY: 6CENSUS: 5DATE:
10/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Staff, Miriam SilvaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility on 10/17/2022 at 9:31 a.m. in order to conduct a health and wellness check and to conduct a follow up on an incident report received by the regional office on 10/14/2022. LPA met with staff, Miriam Silva who was informed of the purpose of the visit.

At the time of the visit there were (4) staff and (1) resident present. LPA was informed by facility staff that all other residents were at their day programs. No health and safety issues were noted at the time of the visit.

LPA collected documentation for Client #1 (C1) pertaining to the incident report and gathered a timeline of events from staff, Miriam Silva. LPA gathered contact information and names of all parties involved in the incident. LPA advised that further documentation may be needed as it becomes available.

An exit interview was conducted where a copy of this report was provided to staff, Miriam Silva.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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