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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603451
Report Date: 01/25/2022
Date Signed: 01/28/2022 10:26:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PACIFICA SENIOR LIVING ESCONDIDOFACILITY NUMBER:
374603451
ADMINISTRATOR:AMY BANAGAFACILITY TYPE:
740
ADDRESS:1351 E WASHINGTON AVETELEPHONE:
(760) 741-3055
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:143CENSUS: 103DATE:
01/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Excutive Director Amy BanagaTIME COMPLETED:
01:53 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management Visit. LPA met with Executive Director Amy Banaga, and discussed the purpose of the visit.

Today's visit is in response to the self-reported death of Resident 1 (R1 - see LIC811 Confidential Names List). R1 passed away at a hospice house, date of death: 12/31/21.

LPA conducted a wellness check at the facility, and no health or safety issues were identified. All staff present have a current criminal record clearance. Residents observed appeared appropriate for the facility. Additional information was obtained on this date regarding R1's death.

No deficiencies were cited or observed on this date.

The Licensee was provided a copy of their appeal rights (LIC9058 01/16), and his signature on this form, acknowledges receipt of these rights. An exit interview was conducted and a copy of this report was provided to Amy Banaga. An email receipt confirms the acknowledgement of these documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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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