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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603451
Report Date: 07/21/2023
Date Signed: 07/21/2023 10:07:58 AM

Document Has Been Signed on 07/21/2023 10:07 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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: 108DATE:
07/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Amy Banaga, Executive DirectorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint control #18-AS-20230703125256. LPA met with Executive Director Amy Banaga and explained the purpose of the visit.

On 07/13/2023, a facility visit was conducted with Shawna Emery, Resident Care Coordinator and LIC9099 dated 07/13/2023 was issued. The purpose of today's visit is to amend the findings of UNSUBSTANTIATED to UNFOUNDED on the LIC9099 issued on 07/13/2023. The amended LIC9099 was provided during today's visit.

An exit interview was conducted and a copy of this report was also provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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