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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604051
Report Date: 08/24/2022
Date Signed: 01/09/2023 08:55:28 AM


Document Has Been Signed on 01/09/2023 08:55 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:PACIFICA SENIOR LIVING RANCHO PENASQUITOSFACILITY NUMBER:
374604051
ADMINISTRATOR:HERNANDEZ, MARIANO QUINNFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENSAQUITOS BLVDTELEPHONE:
(858) 201-6458
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:120CENSUS: 83DATE:
08/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Executive Director, Jill Mcdonald, Memory Care Director, Yesenia Arellano, Regional Nurse, Dustin Banks, Regional Director of Operations, Leslie QuintanarTIME COMPLETED:
03:45 PM
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On 8/24/2022, at 3:15 p.m., Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced case management visit to the facility in response to a self reported incident. The LPA was greeted by Executive Director, Jill McDonald, introduced himself, and discussed the purpose of the visit

On 8/22/2022, the Department received an Unusual Incident Report (LIC 624) of a resident who left the facility, was later located by staff, and was redirected back to the facility. During today's visit, the LPA conducted a tour of the facility, conducted interviews with staff, collected, and reviewed resident records. No deficiencies were cited during today's visit, and future visits may be necessary.

An exit interview was conducted with Executive Director, Jill Mcdonald, Regional Director of Operations, Leslie Quintanar, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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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