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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 03:08:12 PM

COMPREHENSIVE INSPECTION
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:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Theresa Pettepiece, Executive Director (ED)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Theresa Pettepiece, Executive Director (ED). This visit is to conclude the Annual visit that commenced on 8/3/2021.

LPA inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining/ living room areas. LPA inspected 5 resident communities. LPA observed PPE supplies available at front lobby. LPA observed extra gloves available in common areas. LPA observed Office Receptionist conducting wellness check and documenting information on sign in sheets. LPA observed during meal times, no more than 4 residents to a table.

LPA inspected the Mediation room. LPA observed medications locked and stored per resident, proper disposal procedures implemented, MedTech preparing medications for residents and documenting. LPA met with LVN Reshmika Sharma (S1). S1 demonstrated how medications are logged and how Medtechs communicate any changes/ updates throughout the day and between changes in shifts. S1 stated they have Sandi Flores Consultant Group complete a training and audit every 6 months. Next audit is scheduled for week of 8/16/2021.

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

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MODESTO
FACILITY NUMBER: 507004251
VISIT DATE: 08/09/2021
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809 CONT. >>>>>>>>>>>>>>>>>>>>>>

LPA reviewed 5 staff files and 5 resident files. All files completed. 39 staff vaccinated and 56 residents vaccinated. 4 residents have chosen not to be vaccinated due to personal reasons.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with ED and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
LIC809 (FAS) - (06/04)
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