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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 05/20/2024
Date Signed: 05/20/2024 01:04:24 PM

Document Has Been Signed on 05/20/2024 01:04 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/
DIRECTOR:		NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 60CENSUS: 56DATE:
05/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Marketing Director - Connor PerfumoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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*** This is an amended report regarding beginning and end time. Report should reflect the correct time indicating that LPA ended time in facility at 1:00pm not 12:00pm.***

On 05/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit to make observations through out the facility in conjunction with complaint visit on this day.

LPA made staffing observations on this day and requested a copy of the weekly staff schedule. LPA discussed staffing levels with Marketing Director - Connor Perfumo.

No citations issued.

Report discussed with Connor. Copy provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2024
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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