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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603735
Report Date: 07/31/2020
Date Signed: 08/03/2020 08:31:24 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 OCEANSIDEFACILITY NUMBER:
374603735
ADMINISTRATOR:JONETTA EADSFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 618-5608
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: 108DATE:
07/31/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Jonetta Eads, AdministratorTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA), Jonathan Pineda conducted an unannounced tele-visit to conduct a case management visit regarding an unusual incident report submitted to CCL on 7/15/20. LPA identified himself and spoke with Jonetta Eads, Administrator.

It was reported that on 7/15/20, Resident 1 (R1) (Refer to LIC 811 for Confidential List of Names)
fell in their room and sustained a hip fracture. Interview and a review of R1’s Physician’s Report dated 11/19/19 and Plan of Care dated 11/22/19 revealed that R1 resides in Assisted Living and is determined to be mostly independent and able to communicate their needs. R1 requires assistance with bathing, dressing, and ambulation. On 7/13/20 at approximately 11:00pm, R1 called and requested for a Tylenol and mentioned he had fallen. R1 was assessed and facility asked R1 if he wanted to go to the hospital. R1 refused at that time. R1 was provided Tylenol as requested. Two-hour well checks were conducted throughout the night. During one of the well checks, staff asked R1 again if he wanted to go to the hospital and R1 refused again. At approximately, 10:30am on 7/14/20, R1 complained of pain. Facility staff called 911 and R1 was transported to the hospital. Interview and record review revealed that facility held an employee In-service regarding their Clinical Fall response policy to ensure 911 is always activated.

Based on interview and record review, R1 was of sound mind and able to communicate their needs. LPA did not observe any culpability. No deficiencies were cited during today’s tele-visit.

An exit interview was conducted with Jonetta Eads and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Administrator via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Jonathan C PinedaTELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020
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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