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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 05/12/2023
Date Signed: 05/12/2023 11:05:25 AM

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
02/21/2023 and conducted by Evaluator Carol Fowler
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230221095016
FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:CASTRO, GILBERT MFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:90CENSUS: 54DATE:
05/12/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:GILBERT CASTRO EXECUTIVE DIRECTORTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not secure resident's medications as required.
INVESTIGATION FINDINGS:
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On 5/11/2023 at 9:50 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegations. Upon arrival, LPA met with Executive Director, Gilbert Castro and explained the reason for the visit.

During the course of the investigation LPA interviewed 3 staff (S1, S2 and S3) and requested the following documents: Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record (CSMDR), progress notes from the months of December 2022 to January 2023, case notes, emergency contact and identification, physician’s report, appraisal needs and services, and incident reports (December 2022) for R1, R2 and R3.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20230221095016
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: 05/12/2023
NARRATIVE
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Continue from LIC9099

Staff did not secure resident's medications as required.

Interview and observation revealed that Med Techs (Medical Technicians) pre-pour medication into medication cups with resident’s apartment numbers written on them. S1 stated that when passing morning and bedtime medication that medication is poured into medication cups with room numbers on them, they are placed into a basket and put onto an unlocked pushcart and distributed to residents in their apartments. Allegation is SUBSTANTIATED

Based on LPA observations, record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.



Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230221095016
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2023
Section Cited
CCR
87465(h)(2)
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(h) The following requirements... centrally stored: (2) Centrally stored medicines... to persons... the... medication. This requirement was not met as evidence by:
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Administrator will review and understand regulation and send self-certification to CCLD no later than POC date.
Administrator will conduct in-service training for all Medical Technicians on the importance of keeping medication in a safe and locked place inaccessible to residents in care.
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Based on LPAs observation licensee did not comply with the section cited above by not securing medication when being delivered to resident’s apartment which poses and immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/21/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230221095016

FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:CASTRO, GILBERT MFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:90CENSUS: 54DATE:
05/12/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:GILBERT CASTRO EXECUTIVE DIRECTORTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not administer medications as prescribed
Staff did not properly document resident's medication as required.
Staff are not properly trained.
INVESTIGATION FINDINGS:
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On 5/12/2023 at 9:50 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings for the above allegations. Upon arrival, LPA met with by Executive Director, Gilbert Castro and explained the reason for the visit.

During the course of the investigation LPA interviewed 3 staff (S1, S2 and S3) and requested the following documents: Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record (CSMDR), progress notes from the months of December 2022 to January 2023, case notes, emergency contact and identification, physician’s report, appraisal needs and services, and incident reports (December 2022) for R1, R2 and R3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230221095016
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: 05/12/2023
NARRATIVE
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Continue from LIC9099

Staff did not administer medications as prescribed.

RP stated that R1 was given a wrong dose of medication, based on information obtained from the MAR (medication administration record) shows that R1 received the correct dosage, the MAR was signed by staff or documented R1 was out of facility along with the dates. Allegation is UNSUBSTANTIATED.

Staff did not properly document resident's medication as required.

LPA conducted record reviewed and interviews with staff, the MAR (medication administration record) shows medication was given as prescribed. During interviews staff stated that there was no wrong documentation during R1’s residency at the facility. Allegation is UNSUBSTANTIATED.

Staff are not properly trained.

LPA conducted interviews and record review which revealed Med Techs (Medical Technicians) attend an online training that covers administering medications such as Introduction to Medication Management, Medication Order and Working with the Pharmacy Reducing Medication Errors: PRN Medications and then complete and pass Medication Management Final Test, and then take and pass a RCFE Medication Orientation Final Exam and then on to on-the-job training. Allegation is UNSUBSTANTIATED

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview conduct and a copy of report provided to Administrator.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5