374604300-10-25-2023-08-AS-AROS-CWY4NT-20231025191540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 10/25/2023
Date Signed: 10/25/2023 07:16:01 PM

Document Has Been Signed on 10/25/2023 07:16 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PACIFICA SENIOR LIVING OCEANSIDE		FACILITY NUMBER:	374604300
ADMINISTRATOR:	BANKS, JAQUELINE		FACILITY TYPE:	740
ADDRESS:	5508 AVENIDA PACIFICA WAY		TELEPHONE:	(760) 978-6602
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	165	CENSUS: 113	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:			TIME COMPLETED:	04:30 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	Licensing Program Analyst (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Sales Director, Jiovani Anderson-Diaz after identifying herself and stating the purpose of the inspection. The facility serves one hundred sixty five (165) non- ambulatory elderly residents age sixty (60) and above; of which six (6) may be bedridden and may use designated rooms. There is an approved hospice waiver for fifteen (15). With approval for delayed egress and secured perimeters.. LPA was accompanied by the Sales Director, Jiovani Anderson-Diaz during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. No bodies of water are on premises. Passageways were free from obstructions. According to Sales Director Anderson-Diaz, there are no weapons and/or ammunition stored on the premises. Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked hall closet. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 10/25/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. Medications were labeled, as required, and stored in locked areas.

Staff records review verified that all staff have Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. At the time of visit current First Aid certificats and First Aide/CPR certificates could not be produced. Resident records reviewed for a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current.

LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of In-service training procedures. Transportation procedures were reviewed and complaint. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted, this report was discussed with Sales Director, Jiovani Anderson-Diaz. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to the by Sales Director, Jiovani Anderson-Diaz.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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