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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:36:01 PM


Document Has Been Signed on 03/10/2022 02:36 PM - 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: 40DATE:
03/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa Pettapiece and Rashmika SharmaTIME COMPLETED:
01:45 PM
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On March 10, 2021, A meeting was conducted virtually, via Microsoft Teams. The purpose of this meeting was to discuss new rash/scabies cases. Present in the meeting were Regional Manager Krystall Moore, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst Avelina Martinez, Nurse Cristina Wong, facility representatives include; Theresa Pettapiece, Rashmika Sharma, and Local Public Health representatives, Gorlia Xiong, Payeng Moua, Michele Johnson.

During the meeting, the following items were discussed:
  • Scabies Scrape Testing
  • Infection Control
  • Line List
  • PPE use
  • Staff Symptom Monitoring


The facility has stated they will do the following:
  • Provide Employee/Resident Scabies/Rash Line List
  • Continue to implement rash/Scabies outbreak infection control.
  • Monitor residents and staff for rash/Scabies symptoms.
  • Provide daily rash/Scabies updates to Local Public Health and CCLD.
  • Immediately report new rash/Scabies case to Local Public Health and CCLD.


Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with Theresa Pettapiece, and a copy of this report was provided 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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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