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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 01/05/2022
Date Signed: 01/05/2022 02:25:11 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: 42DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rashmika Sharma and Lindsey BeckettTIME COMPLETED:
11:00 AM
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On January 5, 2022, A meeting was conducted virtually, via Microsoft Teams. The purpose of this meeting was to discuss rash/scabies outbreak and Covid-19. Present in the meeting were: Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Manager Stephanie Doud, Licensing Program Analyst Avelina Martinez, and Licensing Program Analyst Maja Jensen Michael Acosta Fay, Peter Vue Karen Johnson, Payeng Moua, Esketa Seeba, Melissa Flaherty.

Community Care Licensing staff identified themselves and discussed the purpose of the virtual visit and the elements of the case management visit with Rashmika Sharma and Lindsey Beckett.
Topics Discussed During Virtual Visit:
  • Rash/Scabies Outbreak-Continue to monitor residents and employees for 6 weeks after last cleared Rash/Scabies case.
  • Infection Control- Continue to disinfect commonly touch surfaces. Disinfect common furniture after each use.
  • Rash/Scabies Line List- Continue to email weekly line list to Community Care Licensing Department and Local Public Health.
  • Covid-19 Line List- Email a daily line list to Community Care Licensing Department and Local Public Health.
  • N95 Fit Testing- Conduct fit testing for all employees by 01/07/2022
  • Covid-19 Mitigation Plan- Continue to implement LIC 808 Covid-19 Mitigation Plan
  • Covid-19 Isolation Unit. Create a positive wing for positive residents
  • Covid-19 Screening for Visitors and Employees- Continue screening process.
Items requested by Community Care Licensing Department:
  1. Weekly Rash/Scabies Line List
  2. Daily Covid-19 Line List

An exit interview was conducted. This report was provided to the facility 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) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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