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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 12/01/2020
Date Signed: 12/03/2020 08:34:42 AM

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: 58DATE:
12/01/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Deborah LucasTIME COMPLETED:
11:45 AM
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
On 12-01-2020 at 9:00 AM, Licensing Program Analysts (LPA) Avelina Martinez conducted an unannounced case management visit. LPA Martinez met with Deborah Lucas and explained the purpose of today's visit.

During today's visit, LPA Martinez followed up on fire clearance inspection that was requested by Community Care Licensing. During the visit, it was learned that a fire inspection was conducted by Modesto Fire Department. The following issues were noted:
        1. Exposed Electrical Wiring in the riser room.
        2. Delayed Egress signs required on all doors with delayed Egress.
        3. Smoke Detectors
        4. Spacers required in the Monterey Building's riser room
        5. replace keys in the knox Boxes
        6. Sprinkler system not facing the street
        7. Carbon Monoxide detectors are required in the hallways leading up to sleeping areas.
LPA Martinez will follow up on the above mentioned issues. LPA Martinez will be following up with Deborah Lucas on 12/04/2020. An exit interview was conducted with Deborah Lucas. A copy of this report was provided to Deborah Lucas via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
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