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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 08/25/2020
Date Signed: 08/25/2020 04:08:55 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:
374604300
ADMINISTRATOR:EADS. JONETTAFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 618-5639
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: 105DATE:
08/25/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jonetta Eads, AdministratorTIME COMPLETED:
04:08 PM
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Licensing Program Analyst (LPA) Jonathan Pineda, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct Comp III. The facility is undergoing a change of ownership. LPA contacted Jonetta Eads by telephone to commence the tele-visit via FaceTime due to COVID-19. The fire department completed their inspection 7/7/20. Facility is approved for one hundred fifty-nine (159) non-ambulatory elderly residents of which six (6) may bedridden. Rooms 1102, 2101, 3102, 4101, 5101, 5102 approved for bedridden use. Approved for delayed egress. Hospice Waiver for fifteen (15).

LPA toured the facility inside and out. Delayed egress was observed to be functioning properly. Adminstrator advised there are no ammunition, weapons or guns stored in the property. Resident rooms were observed with required furnishings. Personal bathrooms were equipped with grab bars and non-skid surfaces. Hot water temperature in restrooms used by the residents measured between 105 - 120 degrees Fahrenheit. All rooms were observed with functional pull chord. The kitchen is fully stocked and has a seven day supply of perishable and non-perishable foods. Medications were observed locked and inaccessible to residents. Outdoor and indoor passageways were free from obstructions. Discussed with the applicant continuing operation requirements, record keeping, reporting requirement and physical plant compliance.

The Pre-licensing and Component III were completed on today's date. Facility is ready for Licensure pending management approval. This is a change of ownership application and there are one hundred and five (105) residents currently in care. An exit interview was conducted with the Jonetta Eads, via telephone and a copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) was provided. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Tony GirolamiTELEPHONE: (619) 767-2301
LICENSING EVALUATOR NAME: Jonathan C PinedaTELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
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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