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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:08:07 PM


Document Has Been Signed on 09/11/2024 04:08 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:MCGRANAHAN, JULIETFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
09/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Juliet McGranahan, AdministratorTIME COMPLETED:
04:07 PM
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LIcensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 09/11/2024 to conduct an inspection to clear a Plan of Correction regarding toxins being accessible to residents in care. LPA inspected 4 out of 4 kitchens and found locks were in place to keep toxins/soaps/hazardous materials/sharps inaccessible to residents.

Staff training has taken place and AM staff was observed putting the training into practice.

LPA discussed the quality of the locks and the proper use with the Administrator. Administrator and Memory Care Director, Lorraina Madrigal, agreed to monitor the proper use of the locks and that staff continue safe practices and protocols.

No deficiencies were cited during this visit.

LPA conducted exit interview with Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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