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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604544
Report Date: 05/03/2023
Date Signed: 05/03/2023 09:24:13 AM


Document Has Been Signed on 05/03/2023 09:24 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: 107DATE:
05/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Business Office Manager Rebecca TovesTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Plan of Correction (POC) visit to confirm that a citation, which was issued on 03/29/2023, has been corrected. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Manager Rebecca Toves.

The following citation was reviewed during today's visit:

87705(j) Care of Persons with Dementia: On 04/27/2023, Executive Director Emily DeLaBarre notified LPA that licensee had installed a staff alert auditory device on the perimeter door located within the facility's Assisted Living "Stairwell 1 Exit Route." During today's 05/03/2023 site visit, LPA, accompanied by Toves, observed and tested this device, finding that it was working and audible. The Plan of Correction is thus completed/satisfied.

No new deficiencies were identified or cited during today's visit.

An exit interview was conducted with Toves, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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