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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:16:45 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: 60DATE:
08/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Theresa Pettapiece TIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs ) Avelina Martinez and Arlene Garcia conducted an unannounced case management visit on 08/03/2021 to amend a citation associated with complaint 27-AS-20201001105247 . LPAs identified themselves and discussed the purpose of the case management visit with Theresa Pettapiece.

As a result of the appeal findings, it was determined citation 87465(a)(i) Incidental Medical and Dental Care will be reduced to a citation B. LPA Martinez went over the citation revision with Theresa Pettapiece, and an exit interview was conducted. In addition, a copy of this report was given to Theresa Pettapiece.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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