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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 08/09/2021
Date Signed: 08/10/2021 03:10:50 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:DEBORAH LUCASFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 60DATE:
08/09/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Theresa Pettapeice, Executive DirectorTIME COMPLETED:
01:00 PM
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LPA Arlene Garcia conducted an unannounced POC visit to clear citations issued on 8/3/2021.

LPA toured the facility and observed the egress notification lighting to be functioning and in working order.

Administrator/Licensee letter to provide a plan that will assist residents with feeding needs suggested serving meals to these residents 30 minutes earlier. After touring and discussing with staff and ED, there was enough staff scheduled in the facility. Proper utilization of staff was decided to be more efficient. LPA observed a Medtech to be available when contacted over walkie. LPA observed support staff available. ED will utilize these staff to support the communities to meet the residents needs.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
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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