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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604177
Report Date: 11/17/2022
Date Signed: 11/17/2022 11:14:49 AM


Document Has Been Signed on 11/17/2022 11:14 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 BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:LEON II, RENEFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 102DATE:
11/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Executive Director, Emily Delabarre and Regional Director of Operations, Kathleen Calobeer TIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced case management visit at the facility. LPA gained access to the facility, met with Executive Director, Emily Delabarre and Regional Director of Operations, Kathleen Calobeer and explained the purpose of the visit which was related to a complaint investigation.

During this visit, LPA reviewed resident 1’s (R1 – See LIC 811 Confidential Names List) Physician’s Report and Care Plan with Executive Director. LPA reviewed Title 22, Division 6, Chapter 8, Article 12, Dementia, Section 8705, Care of Persons with Dementia with Executive Director. LPA advised the Executive Director Physician’s Reports needed to be conducted annually or sooner if there is a change and dated. LPA further advised Executive Director that a reappraisal, or observation indicates that the residents care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident and signed and dated. Technical Advisory given.

An exit interview was conducted with Executive Director, Emily Delabarre and Regional Director of Operations, Kathleen Calobeer and a copy of this report and Licensee/Appeals Rights (LIC 9058 01/16) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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