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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 01/07/2025
Date Signed: 01/07/2025 05:23:28 PM

Document Has Been Signed on 01/07/2025 05:23 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR/
DIRECTOR:		BERTUCCI, GLENDA TFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 90CENSUS: 50DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Glenda Bertucci, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On 01/07/24 around 10:45 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Glenda Bertucci, Executive Director (ED) and explained the purpose of the visit. ED currently holds a standard certificate (#7016878740) exp. 08/13/2026. The facility’s fire clearance was approved for forty (40) non-ambulatory residents.

Upon arrival, LPA observed several residents in the main lobby conversing and lounging together. Additional staff and residents were also in the dining area for breakfast. Staff and residents were moving about throughout the facility's common areas as well. LPA toured the facility including, but not limited to the common areas, bathroom, dining area, nurses station, front courtyard, 1st, 2nd and 3rd floors. The facility consists of individual apartments; each floor has an activities area, tabletop games, books, music, and a television on the 1st floor. All outdoor and indoor passageways were free of obstruction. There were no bodies of water present. A comfortable temperature was maintained at the facility. The facility has an emergency food supply on site and contracts with US Foods twice weekly for deliveries. LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared bathroom was measured at 109.8 degrees Fahrenheit (F) with hand washing signs, soap, paper towels, and garbage cans; the areas were safe, and sanitary. On site laundry facilities are available. PPE, sanitizer, and paper goods remain sufficient. Safety drill completed 12/18/24, fire extinguisher observed full and last inspected 04/15/24.

Continued on LIC809C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING SAN LEANDRO
FACILITY NUMBER: 015601394
VISIT DATE: 01/07/2025
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...continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Emergency Disaster Plan was current.

Five (5) staff and seven (7) residents records were reviewed and were complete.

The following forms are to be updated and submitted to CCLD:
-Resident Roster (Reviewed)
-LIC500 Personnel Report (Reviewed)
-LIC308 Update Designation of Administrative Responsibility (Reviewed)
-LIC610D Emergency Disaster Plan (Reviewed)


Exit interview conducted and a copy of this report provided to ED.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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