<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604134
Report Date: 09/29/2023
Date Signed: 09/29/2023 12:15:30 PM


Document Has Been Signed on 09/29/2023 12:15 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: 116DATE:
09/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:ADMINISTRATOR, MIKE MCCOYTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 29, 2023, Licensing Program Analyst (LPA), Venus Mixson
arrived unannounced to the facility to conduct a Health and Safety Visit and met with the Administrator Mike McCoy.

LPA Mixson toured the facility along with the Administrator. LPA Mixson observed facility clean, neat, and well organized. The utilities were observed to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide assistance to the residents as needed. LPA Mixson assessed the available food supply and observed 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 and locked on med carts and in the med room. There were no Health and/or Safety concerns observed while conducting the tour of the facility at this time. The facility had the required Regulation postings. The LPA observed an activities schedule, the resident council minutes and schedule of the next meetings.
LPA Mixson observed the environment was positive and the residents were welcoming and greeting staff and visitor who arrived.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and/or the welfare of the residents in care. No deficiencies were cited during today's visit.

An exit interview was conducted and a copy of this report was provided to the Administrator Mike McCoy.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1