<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 10/11/2021
Date Signed: 10/11/2021 12:11:41 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:THERESA L PETTAPIECEFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 59DATE:
10/11/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lindsay BeckettTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct a Case Management visit.

LPA met with Lindsay, and stated the purpose of todays visit. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents.

This visit was to confirm receipt of the accusation and review the Health and Safety Code Section 1569.38. Which includes, but not limited to, the instructions regarding the requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a conspicuous location advising that an action is pending.

Licensee was informed that CCL shall receive copies of the notifications to all residents and/or responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements.

Licensee was also advised to contact the Legal Division with any questions regarding Notice of Defense.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit.

Exit interview conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1