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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:55:20 PM

Document Has Been Signed on 07/25/2022 03:55 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 87DATE:
07/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cristina Miller - Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin, conducted an unannounced visit to the facility to initiate the investigation complaint #18-AS-20220722151836. The LPA Colvin met with Executive Director Cristina Miller and informed her of the purpose of the visit.

LPA Colvin observed that the facility has working utilities, plenty of staffing in place, and was receiving a commercial food service delivery at the time of LPA Colvin's inspection.

No immediate health and safety concerns were observed at this time.

An exit interview was conducted with Executive Director Cristina Miller and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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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