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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603451
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:44:36 PM

Document Has Been Signed on 11/06/2024 01:44 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 ESCONDIDOFACILITY NUMBER:
374603451
ADMINISTRATOR/
DIRECTOR:
AMY BANAGAFACILITY TYPE:
740
ADDRESS:1351 E WASHINGTON AVETELEPHONE:
(760) 741-3055
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 143CENSUS: 113DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:ADMINISTRATOR, SHAUN MCGUIRKTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On November 06, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Shaun McGuirk. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for (143) Elderly Adults and is currently operating at a capacity of (113) Elderly Adults (740).

LPA Mixson toured the facility along with the Administrator and made observations pertaining to the annual visit. LPA inspected the facility inside and outside there were no obstructions or debris to the indoor or outdoor passageways at the time of this visit. Additionally, there were no bodies of water on the premises. The facility is a multi-level building located at 1351 E. Washington Ave Escondido, CA. 92027.

Physical Plant: The facility phone number is (760) 741-3055 and it is operable. LPA Mixson observed a sampling of the residents’ living units, and each was equipped with required furniture as per Title 22. LPA Mixson inspected a sample of the facility restrooms, and the hot water temperature tested within regulations. The restrooms sampled were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. LPA Mixson observed required postings such as "If you See Something, Say Something,” the "Personal Rights," and the PUB 475. The cleaning supplies and sharp items were kept locked and inaccessible to the residents in care. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit.

Medications: Were locked and inaccessible to residents in care, and there was a sufficient supply of medication for each resident. The overall facility is clean, the furniture is in good condition. The facility heating system and other appliances were operable currently at the time of this visit. Administrator informed LPA there were safety lights for night throughout the facility.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly, and sharp items are locked.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 ESCONDIDO
FACILITY NUMBER: 374603451
VISIT DATE: 11/06/2024
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Care & Supervision/Administration: Adequate staff are present for the supervision of resident in care. Floor plans, telephone numbers and personal rights were found posted in the facility. The listed administrator possesses a current administrator’s certificate with an expiration date of 12/23/2024.

Records Reviewed and Resident/Staff Files: LPA reviewed five staff files and reviewed the facility's staff schedule. The staff files reviewed have criminal clearance and updated First Aid Certification. Five resident files were reviewed and possessed required paperwork.



Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards. Drills are conducted quarterly and one per shift.

Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.



There were deficiencies observed and/or cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted where a copy of this report was discussed and given to Administrator, Shaun McGuirk.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
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