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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:56:38 PM

Document Has Been Signed on 10/20/2023 03:56 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: 78DATE:
10/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Yolanda Garcia, Resident Service DirectorTIME COMPLETED:
04:00 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 to follow up on additional information for resident's death that occurred on 9/14/2023. LPA spoke with RSD, Yolanda Garcia and gathered documentation.

No deficiencies were cited during this visit.

An exit interview was conducted and a copy of this report LIC 809 were provided to Yolanda Garcia.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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