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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604539
Report Date: 07/15/2022
Date Signed: 07/15/2022 12:09:32 PM


Document Has Been Signed on 07/15/2022 12:09 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 ENCINITASFACILITY NUMBER:
374604539
ADMINISTRATOR:WATKINS, MELISSAFACILITY TYPE:
740
ADDRESS:504 S EL CAMINO REALTELEPHONE:
(760) 452-0615
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:90CENSUS: 56DATE:
07/15/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Melissa WatkinsTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct a Component III. The facility is undergoing a change of ownership, and is approved for ninety (90) non-ambulatory residents. Per Fire Inspection Request received by the Department, the fire clearance was granted by the Encinitas Fire Department, on 1/25/2022.

The LPA was greeted by Executive Director, Melissa Watkins, identified himself himself and disclosed the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. The LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of Personal Protective Equipment (PPE).

Additionally, the LPA observed exterior and interior passageways were free from obstructions. All of the residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. The facility was stocked with a 2 day supply of perishable and a 7 day supply of nonperishable food items. Medications were observed to be locked and inaccessible to residents in care. There were no pools/ bodies of water accessible to residents. Per the Executive Director, there were no firearms, nor ammunition at the facility. The LPA also discussed continuing operation requirements, record keeping, reporting requirement and physical plant compliance.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ENCINITAS
FACILITY NUMBER: 374604539
VISIT DATE: 07/15/2022
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 Facility is ready to be licensed pending management approval. This is a change of ownership application and there are fifty-six (56) residents currently in care. An exit interview was conducted with Executive Director, Melissa Watkins, to whom a copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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