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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604134
Report Date: 03/28/2023
Date Signed: 03/28/2023 01:18:47 PM


Document Has Been Signed on 03/28/2023 01:18 PM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PACIFICA SENIOR LIVING VISTAFACILITY NUMBER:
374604134
ADMINISTRATOR:ENCISO, KARENFACILITY TYPE:
740
ADDRESS:760 EAST BOBIER DRIVETELEPHONE:
(760) 941-1480
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:252CENSUS: 112DATE:
03/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:ADMINISTRATOR, MIKE MCCOY.TIME COMPLETED:
01:38 PM
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On March 28, 2023, Licensing Program Analyst (LPA), Venus Mixson
arrived unannounced to the facility to conduct a case management visit. LPA Mixson met with Executive Director and explained the purpose of today's visit.
LPA Mixson toured the facility and made observations pertaining to the health and safety of the residents and staff at the facility.
LPA Mixson requested and received pertinent documents. During the tour LPA Mixson observed required postings, staff and residents participation in the day to day activities. There were residents completing lunch in the dining area, and staff assisting residents return to their living quarters.
LPA Mixson observed facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA Mixson assessed the available food supply and observed that the supply exceeds the requirement of a two day supply of perishable foods and a seven day supply of non-perishable foods. Medications were found to be in sufficient supply as well. The temperature was comfortable for the season and time of day. The facility was well light with nature light coming through windows throughout the facility. LPA Mixson was not able to see and speak with Resident number one (R1), whom was away at the hospital for surgery.
There were no Health and/or Safety concerns observed during this visit and no deficiencies were cited.

An exit interview was conducted and a copy of this report, along with the LIC 811 was provided to Executive Director.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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