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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:16:36 PM

Document Has Been Signed on 10/09/2024 04:16 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/
DIRECTOR:		MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 83DATE:
10/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Barbara Bogoje, Executive Director, Mariam Issa, Resident Services DirectorTIME VISIT/
INSPECTION COMPLETED:
04:14 PM
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Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit regarding an update of an incident that took place on June 2, 2024. LPA spoke with Barbara Bogoje, Executive Director and Mariam Issa, Resident Services Director and obtained the information. LPA conducted a health, safety and welfare check of residents in care, there are no issues at this time per ED.

There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22.

An exit interview was conducted, a copy of this report were provided to the Executive Director, Barbara Bogoje.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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