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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:16:57 PM


Document Has Been Signed on 03/11/2022 12:16 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:
03/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lindsey BeckettTIME COMPLETED:
01:00 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) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 03/11/2022. LPA met with Lindsey Beckett and explained the purpose of the visit.

The purpose of today's visit was to follow up on two new Scabies cases. LPA Martinez toured the facility with Lindsey Beckett on March 11, 2022. LPA Martinez observed R1, and was informed of an ongoing rash. LPA Martinez also reviewed resident 2's medical file, and March 8, 2022 narrative charting note reports R2 continues to have a rash. LPA Martinez requested a new scabies line list that includes R1 and R2. The Scabies line list shall be submitted to Community Care Licensing Department by March 11, 2022 close of business at 5pm. LPA Martinez requested all residents in Central Valley to be screened for Scabies and all written screening documentation shall be emailed to LPA Martinez by March 15, 2022.

An exit interview was conducted, and a copy of this report was given to the facility. No deficiencies cited at this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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