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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:47:31 AM


Document Has Been Signed on 04/28/2023 11:47 AM - 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: 59DATE:
04/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator, Jeffery GolliharTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi conducted an unannounced Case Management-Other inspection at Pacifica Senior Living Vacaville. LPA was greeted at the door by, Administrator, Jeffery Gollihar, and was granted access into the facility. The purpose of this Case Management-Other inspection is to follow up on an Order of Immediate Exclusion letter issued on April 11, 2023.

During the Case Management-Other inspection, Administrator confirmed Excluded Staff Member is not working in the facility or residing in the facility. Administrator disclosed that the Excluded Staff Member has not been at the facility for two years and is also not on their Guardian Roster. LPA obtained a copy of the LIC 500 and the staff schedule. In addition, LPA and Administrator toured the facility including the kitchen, and observed ten staff members supervising the care of residents and two kitchen staff members. Furthermore, Excluded Staff Member was not seen on the premises. Based on evidence obtained during today’s Case Management-Other Inspection, the LPA has verified Excluded Staff Member is not present, employed, or residing at the facility. Verification of removal is complete.

No deficiencies were observed or cited during today's Case Management-Other inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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