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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880550
Report Date: 09/12/2023
Date Signed: 09/12/2023 10:52:18 AM

Document Has Been Signed on 09/12/2023 10:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR:MELISSA POLENDOFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 95CENSUS: 65DATE:
09/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Resident Service Director, Patricia RussellTIME COMPLETED:
11:10 AM
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) Kathleen Banrasavong conducted an unannounced case management visit to the facility. LPA met with Resident Service Director (RSD), Patricia Russell, LPA explained the nature of the visit and was granted entry into the facility.

The purpose of today's visit is to conduct a follow up visit for an Immediate Exclusion letter for an ex-employee named Adriana Silva. Adriana Silva was not present during today’s visit. LPA was informed by the RSD that Adriana Silva has not worked at the facility since June 25, 2021. LPA conducted a tour of the facility. There was no health and safety concerns at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and provided to the Resident Service Director, Patricia Russell.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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