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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 02/09/2022
Date Signed: 02/15/2022 09:46:28 AM


Document Has Been Signed on 02/15/2022 09:46 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:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 61DATE:
02/09/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Melody Lee-AllmondTIME COMPLETED:
01:30 PM
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An informal meeting was conducted today in the Santa Rosa Regional Office via Zoom due to Covid19 precautions. Present in the meeting were, Licensing Program Manager, Kimberley Mota, Licensing Program Analyst, Caitlynn Felias, and Executive Director/Administrator Melody Lee-Allmond, Resident Services Director Solomae Mora, and Wellness Nurse, Oasis Buensalido.

The purpose of the informal office meeting was to discuss concerns that have been identified with the operation of this facility.

The following was discussed during the office meeting:
· SIRs being submitted to CCL timely
· Facility adhering to their mitigation plan
· Timely reporting of positive COVID cases to CCL and Local Public Health

Executive Director confirmed that they are working with Local Public Health (LPH) and Office of Emergency Services. Both agencies have provided training and support.
Facility currently has sufficient staffing and PPE.

No deficiencies were cited during today's visit
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
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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