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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:01:21 PM


Document Has Been Signed on 07/11/2022 12:01 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: 32DATE:
07/11/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascua arrived at this facility unannounced on 07/11/2022 at 10:30 AM to conduct a Health and Safety case management visit. LPAs met with Theresa Pettapiece and explained the purpose of the visit.

During today's visit, LPAs Martinez and Pascua toured the facility and reviewed facility documents. LPA Martinez and Pascua also, inspected the facility kitchen's food supply. The facility has a 30 day supply of PPE, and there is one known case of Covid-19. The facility has been cleared of Noro Virus, and the facility has submitted an infection control plan. Residents appeared to be clean.

Moreover, during this visit, LPA Martinez and Pascua reviewed Unusual Incident reports, and requested documents for resident 1 and Resident 2. LPAs Martinez and Pascua received the requested documents during today's visit.

An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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