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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:59:08 AM

Document Has Been Signed on 11/14/2024 11:59 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PACIFICA SENIOR LIVING OCEANSIDEFACILITY NUMBER:
374604300
ADMINISTRATOR/
DIRECTOR:		BANKS, JAQUELINEFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 978-6602
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 165CENSUS: 101DATE:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Executive Director Jackie BanksTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to conduct follow up regarding an incident report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Jackie Banks.

On 11/5/2024, the Department received an incident report from the facility which described that on 11/1/2024 at approximately 4:45am, Resident 1 (R1) was discovered by facility staff outside in the internal courtyard and had sustained multiple injuries. [Executive Director was provided with an LIC811 Confidential Names List to identify R1] Staff assessed R1 and brought R1 back inside and staff called 911 after R1 was observed to be confused and disoriented. R1 was transported to the hospital where R1 received treatment for the injuries and returned to the facility the same day.

During today’s visit, LPA conducted a health and safety check, observed residents in care, including R1, and reviewed and obtained copies of facility records.

No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Jackie Banks, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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