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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 07/22/2020
Date Signed: 07/22/2020 03:12:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PACIFICA SENIOR LIVING MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 57DATE:
07/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Deborah LucasTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a Covid-19 technical assistance visit on 7/22/20. LPA met with Deborah Lucas and explained the purpose of the visit.

The purpose of today's visit is to follow up on the facility's Covid-19 preparedness plan and to conduct a covid-19 technical assistance visit. LPA Martinez was accompanied by Stanislaus County Public Health: Denise Sanford and Kelly Cardoza.

An exit interview was conducted with Deborah Lucas A copy of this report was provided to Deborah Lucas via email. LPA Martinez emailed the report to Deborah Lucas. Deborah Lucas signed the report, and emailed the report LPA Martinez.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2020
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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