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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603735
Report Date: 03/24/2021
Date Signed: 03/24/2021 01:42:36 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:BANKS, JAQUELINEFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 618-5608
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:0CENSUS: 105DATE:
03/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Executive Director, Jaqueline BanksTIME COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA), Elizabeth Hamilton, conducted an unannounced virtual visit regarding facility closure due to a recent change of ownership effective October 07, 2020. Virtual visits are being conducted due to COVID-19 restrictions and was completed via FaceTime. LPA contacted Executive Director, Jaqueline Banks. LPA identified herself and stated the purpose of the call.

During today's visit, LPA briefly toured the facility and verified the residents placement. Per Executive Director, no residents were relocated as a result of this change of ownership. LPA requested a copy of the notice provided to the residents for facility file and the original license from the Executive Director who stated they would request the corporate office to send the license to the Regional Office.

An exit interview was conducted with Executive Director via FaceTime and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director via email. An electronic receipt of confirmation was requested to be sent by the Executive Director upon receipt of the documents.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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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