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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 07/22/2020
Date Signed: 07/23/2020 11:47:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 55DATE:
07/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:46 PM
MET WITH:Karen NickolaiTIME COMPLETED:
04:30 PM
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On 7/22/20 at 3:46pm Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management inspection via televisit with Administrator Karen Nickolai. This case management was in regards to a self reported incident that was reported to CCLD on July 20, 2020.

LPA requested a copy of Resident 1's (R1) physician report. Karen stated that this is the first time this has happened involving R1. She also stated that he has dementia. Karen has taken the proper precautions to prevent this from happening again by having staff monitor Resident 1 1:1, talking to Primary Care Physician and family, and installing a lock from the outside on room #206 the room Resident 1 went to. A SOC341 has also been completed and sent to the San Mateo County Ombudsman.

No deficiencies cited today. This report was discussed, reviewed and a copy was emailed to Administrator Karen Nickolai for signature due to Covid-19 procedures.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020
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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