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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 05/19/2021
Date Signed: 05/19/2021 04:00:42 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) 978-6602
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: DATE:
05/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Business Office Manager, Zayra CarrascoTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Lizzette Tellez conducted a case management visit. LPA was met by Jessica Moran, Receptionist, and granted entry into the facility. LPA met with Zayra Carrasco, Business Office Manager, and discussed the purpose of the visit.

This visit was initiated due to self-reported incidents, which occurred on April 6, 2021, and April 8, 2021, involving Residents #1, and 2 (R1-R2), respectively. Ms. Carrasco was provided with Confidential Names Form, in order to identify R1-R2. The Licensee's authorized representative self-reported these incidents by submitting Forms LIC 624 - Incident Report to Community Care Licensing (CCL), which were received by CCL on April 13, 2021, and April 14, 2021.

During today's visit, LPA reviewed resident records, conducted interviews, and briefly toured the facility.

No deficiencies were issued during this visit. An exit interview was conducted with Ms. Carrasco. A copy of this report along with Applicant Rights (LIC9058 01/16) was provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon rec eipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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