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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:39:27 PM


Document Has Been Signed on 12/19/2022 12:39 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:JEFFERY GOLLIHARFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 53DATE:
12/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Resident Care Coordinator, Crystal CrowTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Resident Care Coordinator, Crystal Crow, and was granted access into the facility.

During the course of the Case Management-Incident inspection, LPA reviewed and discussed the SOC 341's that were forwarded to CCL on December 5, 2022. LPA requested the following documents:

-LIC 602 for Resident #1 (previous and most current)
-Two week notice for staff member
-Pre-Appraisal for Resident #1

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator due to printer issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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