<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 10/09/2023
Date Signed: 10/09/2023 02:05:27 PM

Document Has Been Signed on 10/09/2023 02:05 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:MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 81DATE:
10/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mark Pacia, Executive Director, Yolanda Garcia, Resident Service DirectorTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced case management visit to the facility. On 9/14/2023, CCLD received report of a resident's death. The visit was to follow up on resident #1 (R1)s death. LPA met with Executive Director Mark Pacia and Resident Services Director Yolanda Garcia and explained the purpose of today's visit.

During LPA's visit, LPA reviewed and obtained copies of pertinent documentation and interviewed two (2) staff. LPA was informed by Resident Services Director regarding the events that led up to R1's death whom passed away on September 14, 2023. LPA was informed that R1 had not been feeling well since the morning prior to her passing and R1 refused to be sent out to the hospital when asked by staff.

The preliminary cause of death is unknown at this time. LPA advised Mark Pacia and Yolanda Garcia to send a copy of the death certificate to the department as soon as it is available.

No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list), were provided to Mark Pacia and Yolanda Garcia.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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 1