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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604544
Report Date: 07/05/2022
Date Signed: 07/05/2022 11:05:53 AM


Document Has Been Signed on 07/05/2022 11:05 AM - 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 BONITAFACILITY NUMBER:
374604544
ADMINISTRATOR:MARKOVICH, PAULFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:145CENSUS: 103DATE:
07/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Rene LeonTIME COMPLETED:
11:09 AM
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Licensing Program Analyst (LPA) Ramon Serrano, conducted an announced Pre-Licensing inspection. LPA met with Executive Director (ED) Rene Leon and we discussed the purpose of the visit. Facility is applying to serve 145 residents over 60 years of age. All rooms at the facility are approved for ambulatory.

During today's visit LPA Serrano was accompanied by ED Rene Leon who conducted a facility tour. LPA observed resident rooms and found them to have proper furnishings, and adequate linens. Sinks accessible to residents had water temperatures measured at 114.1 Fahrenheit. Facility temperature was read at 74 degrees Fahrenheit. Facility had multiple working fire extinguishers. Smoke and carbon monoxide alarms were observed and operational. Facility had preparation space for food service and kitchen was observed to have all needed supplies for food service. Space inside the facility is sufficient for activities. ED Rene Leon stated that there will be no weapons or ammunition kept on the facility property and there is no pool on site. Staff and resident records will be stored in a locked cabinet. There is a shaded outdoor space and appropriate resident activities. All cleaning supplies or potentially hazardous materials were locked. Facility has a locked area for resident medications and first aid kits. Component III was reviewed with ED Rene Leon. The application will be sent to the Centralized Application Bureau for final review and approval.

An exit interview was conducted with ED Rene Leon . A copy of this report along with Licensee Rights (LIC 9098, 01/16) was provided to ED Rene Leon whose signature below verifies receipt of these rights.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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