374604604-3-13-2024-08-AS-JBAD-D3BVKX-20240313163105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604604
Report Date: 03/13/2024
Date Signed: 03/13/2024 04:31:21 PM

Document Has Been Signed on 03/13/2024 04:31 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PACIFICA SENIOR LIVING POWAY		FACILITY NUMBER:	374604604
ADMINISTRATOR:	AZEMIKHAH, CAMERON		FACILITY TYPE:	740
ADDRESS:	12750 GATEWAY PARK ROAD		TELEPHONE:	(858) 451-9933
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	72	CENSUS: 45	DATE:	03/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Cameron Azemikhah		TIME COMPLETED:	04:45 PM

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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Cameron Azemikhah .

According to the facility’s license, the facility has a maximum capacity of seventy-two (72) residents, all of whom may be non-ambulatory. During today’s inspection, there were a total of forty-five (45) residents in care.

LPA, accompanied by Cameron Azemikhah, toured the interior and exterior of the facility, and inspected resident rooms. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Hot water temperature at taps accessible to clients were all compliant.

There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING POWAY	FACILITY NUMBER: 374604604
	VISIT DATE: 03/13/2024

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No pools or bodies of water were observed on the premises. Per the administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible.

Confidential records were stored in locked areas. Azemikhah also presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection. LPA issued one (1) technical violation and one (1) technical assistance.

An exit interview was conducted with Azemikhah, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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