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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:04:13 AM


Document Has Been Signed on 07/28/2022 11:04 AM - 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: 30DATE:
07/28/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Lindsay BeckettTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascua arrived at this facility unannounced on 07/28/2022 at 10:30 AM to conduct a Health and Safety case management visit. LPAs met with Lindsay Beckett and explained the purpose of the visit.

The purpose of the visit today, is in response to Health and Safety visit. Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. LPAs also toured the facility. During the tour, LPAs inspected resident room and observed residents. During the time of visit, there were 30 staff in the facility. The facility was sanitary, there were no deficiencies observed during the tour.

LPA Martinez reviewed resident 1 (R1) facility file as a result of an incident that involved R1. After R1's reported incident, R1 was moved to another community within the facility. It was learned R1 is moving out of this facility at the end of this month. Also, LPA Martinez requested LIC 602 Health Certification form, Facility document, Needs and Service Plan, and police report. LPA Martinez will continue to follow up on this incident.

As a result, of this visit, no deficiencies were cited per Title 22 Regulations. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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