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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:59:48 PM


Document Has Been Signed on 11/07/2023 04:59 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:NOEL FACTORFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 70DATE:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Noel Factor, AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an Annual Required inspection and was greeted by Administrator Noel Factor.

LPA and Administrator toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents' rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. There were fire extinguishers throughout the facility, all that were inspected were fully charged and tested 07/24/2023. Fire Dept. conducted inspection on 11/7/2023. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate #6039807740 for Noel Factor expires on 08/16/2024. Medications were reviewed, centrally stored and locked.

LPA reviewed five residents' files, all residents files have a current medical assessment and care plans updated within the last 12 months. LPA will continue Annual Inspection to review personnel files at a later date.

Exit interview was conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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