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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 11/09/2023
Date Signed: 11/09/2023 05:18:37 PM


Document Has Been Signed on 11/09/2023 05:18 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:
11/09/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Noel Factor, AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to complete the Annual Inspection at Pacifica Senior Living on 11/09/2023.

LPA and Administrator Noel Factor inspected the facility and found the facility clean and odor-free. Residents were engaged in different activities throughout the community: arts and crafts, gardening, games, walking and socializing in each of the cottage great rooms. Snacks were being enjoyed in the courtyard during LPA's visit, and 50's music was being played. Kitchens were inspected and found to be clean and well-organized. Sharps were locked and inaccessible to residents. 4 of the 5 kitchens were having maintenance on kitchen sinks, but did not impact the residents. Shower rooms were equipped with shower chairs, non-skid mats and shower curtains for privacy.

Living rooms were decorated attractively and clean, providing a homey feel to the facility. At the time of visit, LPA found the staff cheerful and interactive with residents.

LPA reviewed 5 staff files and found them to be complete.

No citations issued.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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