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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:27:32 PM


Document Has Been Signed on 06/01/2022 12:27 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: 38DATE:
06/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascual arrived at this facility unannounced on 06/01/2022 at 10:30 AM to conduct a health and safety case management visit. LPAs met with Theresa Pettapice and explained the purpose of the visit.

The purpose of the visit today was to conduct a health and safety check due to facility closing. During the visit, it was learned there were COVID-19 positive cases. As a result, a phone interview was conducted, and a virtual facility tour was conducted on today's visit. The facility has a 30 Day supply of PPE, and has an COVID-19 positive isolation room. The Isolation room has a PPE station outside of the room and has a garbage can with a lid. Facility staff entered the COVID-19 Isolation room, with PPE Gear. The facility is conducting response testing and has limited resident visitation.

There were no citations cited at this meeting. An exit phone interview was conducted with Theresa Pettapiece via telephone. A copy of this report was provided via email due to COVID-19 precautions, 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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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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