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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:53:33 AM


Document Has Been Signed on 09/01/2022 10:53 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: 29DATE:
09/01/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascua arrived at this facility unannounced on 09/01/2022 at 10:21 AM to conduct a Health and Safety case management visit. LPAs met with Theresa Pettapiece and explained the purpose of the visit.

The purpose of the visit today, is in response to Health and Safety check. The health and safety check included overall safety of the facility, which also included food supply inspection, physical plant inspection, resident checks, and staffing checks. During the facility tour with Theresa Pettapiece, LPA's observed residents. The residents appeared to be clean clothes and good health. Moreover, the facility is conducting room renovations. The facility also had an adequate supply of food. The facility was furnished and sanitary. Furthermore, during today's visit, there were 14 staff working. There were no deficiencies observed during today's tour.

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: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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