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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 08/13/2021
Date Signed: 08/13/2021 10:18:04 AM

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:BANKS, JAQUELINEFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 978-6602
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: 109DATE:
08/13/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Administrator, Jackie BanksTIME COMPLETED:
10:09 AM
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Licensing Program Analyst (LPA), Kristina Ryan, initiated an announced case management visit to conduct a health and safety check and review COVID-19 mitigation strategies. The virtual visit was conducted via FaceTime due to COVID-19 restrictions. LPA met with Administrator, Jackie Banks identified herself, and stated the purpose of the virtual visit.

During today's visit, LPA toured the facility and interviewed Jackie Banks. No deficiencies were issued during this visit.

An exit interview was conducted. A copy of this report and Licensee's Rights (9058 01/16) were provided to Ms. Banks via electronic mail. An email receipt confirms the acknowledgement of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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