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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 06/08/2022
Date Signed: 06/08/2022 02:40:46 PM


Document Has Been Signed on 06/08/2022 02:40 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: 37DATE:
06/08/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Adam Bandel, leslie Quintanar,Carl Knepler, Theresa Pettapiece, Marlene Nelson, Rashmika Sharma TIME COMPLETED:
02:30 PM
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An office meeting was held via Microsoft Teams on June 8, 2022 at 1:30 PM. The Department explained the purpose of this office meeting to Pacifica Senior Living management staff. The following were in attendance Lead Regional Manager Stephen Richardson, Licensing Program Manager Stephenie Doub, Licensing Program Manager Czarina Camilon-Lee, Licensing Program Analyst Avelina Martinez, Licensing Program Analyst Arielle Pascual; Representatives of Pacifica Senior Living Modesto: Carl Knepler, Theresa Pettapiece, Marlene Nelson, Leslie Quintanar, Adam Bandel, and Rashmika Sharma.

The purpose of today's visit is to review the stipulation adopted on May 27, 2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period.
The Stipulation was reviewed with Pacifica Senior Living Modesto Representatives, who expressed their understanding.

Items discussed at the meeting included, but not limited to:

Stipulation contents
  • Findings
  • Revocation of Licenses and Exclusion to Facilitate Sale of Facilities
  • Future Application For a Licensed Registration Certificate or Approval
  • Civil Penalties
  • Violations of Stipulation Terms
  • Waiver of Appeal/Modification Rights


Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MODESTO
FACILITY NUMBER: 507004251
VISIT DATE: 06/08/2022
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The Licensees/Respondents/Representatives stated they would abide by the following:
  • Abide by the contents/terms of the Stipulation (submit all documents timely)
  • Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly.

CCLD will do the following:
  • Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, 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: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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