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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603735
Report Date: 10/07/2020
Date Signed: 10/07/2020 12:53:16 PM

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: 109DATE:
10/07/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Zayra Carrasco, Business Office ManagerTIME COMPLETED:
12:51 PM
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Licensing Program Analyst (LPA) Jonathan Pineda commenced a Case Management tele-visit regarding a resident’s death. Tele-visit was conducted due to COVID-19. LPA spoke with Zayra Carrasco, Business Office Manager and discussed the purpose of the visit.

An Incident Report and Death Report was submitted to Community Care Licensing (CCL) on 10/7/20 reporting that Resident #1 (R1) experienced a fall at the facility on 9/28/20 and subsequently passed away at the facility the following day, 9/29/20.

During today’s tele-visit, LPA interviewed staff and requested copies of resident records. No deficiencies were cited during today’s visit.

An exit interview was conducted with Zayra Carrasco, Business Office Manager and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Zayra 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: 10/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2020
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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