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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 02/25/2022
Date Signed: 02/25/2022 11:05:55 AM


Document Has Been Signed on 02/25/2022 11:05 AM - It Cannot Be Edited

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: DATE:
02/25/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
11:15 AM
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On 2-25-22 at 9:58am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a plan of correction (POC) visit. LPA met with Theresa Pettapiece and explained the purpose of the visit. A previous citation was issued on 2-1-22 for a dysfunctional fire alarm system. Upon arrival local fire department was on site to test the fire alarm system. LPA toured facility with fire department. All smoke detectors are functioning properly along with corresponding alarms throughout facility. Pull fire alarm system is functioning properly and sounding alarm upon activation. Communication panel was demonstrated by fire department and now properly communicates signal to fire department upon activation. At this time, fire department has authorized the release of fire watch duty for facility and passed new devices installed. Alarm company to submit plans to fire department

Plan of correction is cleared. No deficiencies cited today. An exit interview was conducted with Theresa Pettapiece and a copy of this report was left with Theresa.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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