Pacifica Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by caregiver staff and explained the reason for the visit. House Manager (HM) Marla Punzalan arrived shortly to assist with the visit. Facility is licensed for 6 non-ambulatory residents and 1 maybe bedridden with a hospice waiver for six. Currently there are five residents, of which one is on hospice during today's visit. LPA Tea reviewed five resident files and two staff files. Resident files and staff files contained all the required documentation. The administrator certificate expires on March 27, 2027. LPA Tea along with caregiver toured the facility at 10:00 AM. LPA toured the physical plant, checked the food service, and the first aid kit. The facility is a single-story home that consists of six resident bedrooms, one caregiver room, storage room, six bathrooms, living room, dining room, kitchen, laundry and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and are operational. There are cameras without sound in common areas. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. The water temperature measured between 111.2 to 118.5 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards; doorways were free of obstructions. First aid kit had all the required elements including bandages, dressing, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at the time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and (Annul Inspection continued on LIC809-C) inaccessible to clients underneath the kitchen sink and in the laundry room. The fire extinguisher by the dining room is fully charged. Kitchen appliances for the most part are operational during today's visit. Only one minor issue with a burner on the stove, the ignitor was not working. Facility will replace or fix it as soon as possible. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. LPA observed emergency supplies, food and water supply in the medication closet and garage. Facility provides activities based on resident interests and physical condition. The residents do puzzles, play cards, and do coloring. They walk around the house and the residents go sunbathing in the backyard when the weather permits. At the time of the annual visit, LPA observed residents watching television in their rooms and hanging out in the dining room. One resident had family visiting and was taken out to lunch. LPA reviewed medication storage and administration. Medications are stored in a locked closet by the living room. Medications are being administered per physician. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with House Manager Marla Punzalan and a copy of these reports were given to the facility along with a copy of the LIC858; 859.the state’s words, verbatim · CDSS document, Sep 2, 2025

Type of visit: Required - 1 Year

On June 4, 2024 at 8:50AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with House Manager (HM) Bryan Bernardino and explained the purpose of the visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden and have a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, six (6) bathrooms, living room, dining room, kitchen, and outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with AD There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident 3, Resident Room 4, Resident Room 5, and Resident Room 6. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 112.7 and 115.1 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency supplies and emergency food are stored in the medication closet. The emergency water is stored in the garage. The facility has one (1) fire extinguisher that is charged and was serviced on October 20, 2023, smoke detectors, and carbon monoxide were operable. A working telephone (949-215-2128) remains available. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and clients, and sanitizing stations in common area. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA conducted an audit of three (3) resident files and six (6) staff files. LPA Kim conducted an audit on resident medication and medication administration review. LPA Kim conducted two (2) staff interviews. Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6 Chapter 8). An exit interview was conducted, and a copy of this report was provided to House Manager Bryan Bernardino.the state’s words, verbatim · CDSS document, Jun 4, 2024