015601394-1-26-2023-15-AS-KHOS-CPAVHD-20230222152657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 01/17/2023
Date Signed: 01/26/2023 02:58:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230110113019

FACILITY NAME:	PACIFICA SENIOR LIVING SAN LEANDRO		FACILITY NUMBER:	015601394
ADMINISTRATOR:	CASTRO, GILBERT M		FACILITY TYPE:	740
ADDRESS:	348 W JUANA AVE		TELEPHONE:	(510) 357-1691
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	90	CENSUS: 59	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	03:39 PM
MET WITH:	Gilbert Castro, Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility is in disrepair

INVESTIGATION FINDINGS:

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On 1/26/23 at 1:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to further investigate the the above allegation. LPA met with Gilbert Castro, Administrator. LPA explained the purpose of the visit.

During the investigation LPA conducted interviews, and randomly selected six apartments for inspection. LPA observed the ceiling and walls in one of the residents' apartments with water damage. Residents in the aparment confirmed that there water was leaking into their apartment during the last storm.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the case mangement note dated 1/26/23.

Exit interview conducted, a copy of this report and appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230110113019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PACIFICA SENIOR LIVING SAN LEANDRO	FACILITY NUMBER: 015601394
	VISIT DATE: 01/17/2023

NARRATIVE

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*** This is an amended report***report continues from 9099***

Administrator reported that on 12/21 the facility had issues with heat. Facility maintenance discovered that the condensers on the roof were frozen and covered in ice. Administrator called ABCO Mechanical Contractors for guidance. ABCO recommended turn the unit off and restarting them once the ice had melted. The units were then working properly.

Temperature through out the facility was comfortable. Dining room was 73 degrees, main lobby was 72, second floor lobby was 72 and third floor lobby was 76 degrees. LPA reviewed repair invoices for several repairs to broken thermostats in resident rooms. LPA observed that a space heater was placed in the dining room at the request of a resident felt chilled next to the window.

See amended LIC9099 report dated 1/19/23 for findings.

Exit interview conducted with Executive Director and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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