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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 06/17/2024
Date Signed: 06/17/2024 03:13:44 PM


Document Has Been Signed on 06/17/2024 03:13 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 BRUNO RO, 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:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Manager - Jovy CastroTIME COMPLETED:
03:00 PM
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On 06//217024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with business office director Jovy Castro and explained the purpose of today's visit. According to Jovy the facility does not have a full time administrator but says there are applicants going through the process.

LPA toured the facility inside and outside with Jovy. This is a two level facility. While touring the facility LPA tested the water in random resident rooms and private room bathrooms. Room 104 was tested at 110F, Room 110 tested at 110, Room 217 tested at 110. Resident rooms are observed at random and are maintained to include the required furniture and lighting per regulations. Residents have an adequate amount of linens and incontinence supplies, incidental supplies such as toilet paper and paper towels, as well as PPE as needed. Three fire extinguishers were checked within the facility. Tagged inspection is dated as 11/17/2023. Extinguishers observed are charged and within operating range including the kitchen's fire extinguisher. Carbon monoxide detectors are present through out the facility. Facility is hardwired with smoke detectors, fire alarm pull, and sprinklers. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Main kitchen is on the ground floor of the building. Food deliveries are made weekly. Longer lasting food supplies such as frozen goods, canned goods, dry goods, etc is delivered weekly as well but there is an additional 7 day food supply if a delivery is missed. Residents with modified diet plans or prescription diets are posted and reviewed as in place in the kitchen. Medications are stored and inaccessible in a locked medication rooms and medication carts. There is a medication room on each floor. Medications are stored in secured medication carts that are used to disperse medications through out the facility. On site laundry is available and functioning per observations made. Facility does not handle resident monies. Cleaning supplies are stored in a locked room on the ground floor. Facility does have two janitor carts that are stored in lockable areas on each floor. Facility food menus are posted. Activity calendar and daily calendar as observed during inspection walk through. Emergency egress routes are observed as free and clear of obstructions. Last fire drill was conducted on 04/12/2024.

Facility files, including staff files and resident files, are to be reviewed on a later date.

Report is reviewed with Jovy. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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