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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:46:32 PM


Document Has Been Signed on 10/11/2022 03:46 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
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: 104DATE:
10/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jackie BanksTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management Visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Jackie Banks.

On 9/27/2022, the Department received an incident report regarding an incident involving Resident 1 (R1) that occurred on 9/24/2022. [Jackie was provided with an LIC811 Confidential Names List to identify R1]. On 9/24/2022 at 10:45am, R1 requested to be taken to the hospital due to suicidal ideations. The facility contacted 911 and paramedics arrived at the facility to transport R1 to the hospital at 11:05am. R1 returned to the facility on 9/24/2022 at around 6pm.

During today's visit, LPA toured the facility, interviewed residents and staff, and reviewed and obtained copies of facility documents.

No deficiencies were observed or cited on this date. An exit interview was conducted with Executive Director Jackie Banks, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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