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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603451
Report Date: 10/28/2021
Date Signed: 02/25/2022 04:56:48 PM

Document Has Been Signed on 02/25/2022 04:56 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PACIFICA SENIOR LIVING ESCONDIDOFACILITY NUMBER:
374603451
ADMINISTRATOR:AMY BANAGAFACILITY TYPE:
740
ADDRESS:1351 E WASHINGTON AVETELEPHONE:
(760) 741-3055
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 143CENSUS: 102DATE:
10/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Executive Director Amy BanagaTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced case management visit. LPA identified herself and stated the purpose of the visit to Executive Director Amy Banaga.

The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on October 16, 2021. The facility reported that on October 16, 2021, R1 left the facility (AWOL) and was returned to the facility by police.

On today’s date, LPA toured the facility and conducted a health and safety check. LPA briefly interviewed the Executive Director Amy Banaga and requested copies of additional facility records. No deficiencies were cited at this time.

An exit interview was conducted with Amy Banaga, to whom a copy of this report and the LIC9058 Licensee/Appeal Rights were provided via E-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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