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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 02/13/2024
Date Signed: 02/13/2024 04:13:59 PM


Document Has Been Signed on 02/13/2024 04:13 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: 63DATE:
02/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
04:25 PM
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On 2/13/2024, Licensing Program Analyst, Tobola arrived unannounced for the purpose of a case management for additional updates on facility plan of corrections and to amend a report from a previous visit and was greeted by Acting Administrator, Juliet McGranahan. LPA will need to conduct a visit at a later date to finalized amended report. LPA and Acting Administrator held a discussion with the company clinician and Health Services Director. The party discussed the current plan of developing improved practices for medication assistance and record keeping. The facility was informed that to provide documentation to CCLD for any changes to the facility program plan and protocols. In addition, LPA provide an update on the delivery for new laundry machines to replace the current ones. Lastly, Administrator stated that the facility corporation will not be moving forward with the Technical Support Services at this time.

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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