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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 05/04/2022
Date Signed: 05/04/2022 07:32:55 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
04/28/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220428123317
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: 62DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lisa Lostica/Senior Business Office ManagerTIME COMPLETED:
07:40 PM
ALLEGATION(S):
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-Facility has water leak.

-Resident's bathroom does not have a grab bar installed.

-Facility not maintained at a comfortable temperature.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegations. LPA met with the Senior Business Office Manager Lisa Lostica, and informed the purpose of visit.

LPA obtained copies of resident roster, staff schedule and Maintenance Log, and conducted inteviews. LPA also conducted inspection with Lisa Lostica.

Allegation: Facility has water leak.
LPA conducted interviews, and randomly selected six apartments for inspection. Statements from the staff (S1 and S2) interviewed regarding the leaks were confirmed by LPA throuh inspection. LPA observed the ceiling in the residents' apartment leaking with a bucket placed below to catch the water dripping. LPA observed the ceiling in the bedroom in this aparment with water damage.

.......continued next page

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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 4
Control Number 15-AS-20220428123317
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: 05/04/2022
NARRATIVE
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LPA further observed the ceiling on the hallway on the third floor with sign of water damage and sink faucet in another resident's apartment on the second floor leaking.

Allegation: Resident's bathroom does not have a grab bar installed.
LPA observed one of the residents' apartments on the first floor without grab bar on the shower room.

Allegation: Facility not maintained at a comfortable temperature.
LPA interviewed 2 staff who both indicated that residents complained of the temperature in the dining area. Copy of quotation dated March 2, 2022 confirmed staff's statements that residents were complaining about the temperature. Lisa Lostica indicated that the contract for the job is still yet to be obtained. Resident (R2) interviewed stated the heater in his apartment not working. Review of Maintenance Log revealed heaters on other 3 apartments not working.

Based on interviews and inspection conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099 D. Failure to submit proof of corrections by plan of correction due date and any repeat violations within 12 month period may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Lisa Lostica at the conclusion of exit interview.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220428123317
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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/18/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
-This requirement is not met as evidenced by: -Based on interviews and inspection. the
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Administrator to do the following:
Check all apartments for leak and have the repair needed done. Proof to be submitted by May 18, 2022.
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licensee did not comply with the section above. LPA observed the following: (1) water leaking from the bathroom ceiling and sign of water leak in the bedroom ceiling in one of the residents' apartment; (2) sink faucet leaking in another resident apartment; (3) water damage in the ceiling on the third floor hallway which pose potential safety and personal rights risks to persons in care.
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Type B
05/18/2022
Section Cited
CCR
87303(e)(4)
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87303 Maintenance and Operation
(e) ...(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

-This requirement is not met as evidenced by:
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Administrator to have grab bar installed and submit picture by 5/18/2022.
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-Based on inspection, the licensee did not comply with the section above. LPA observed one of the shower room of the resident's apartment without grab bar which poses potential safety risk to person 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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220428123317
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: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/18/2022
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times.
-This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not comply with the section above.
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Administrator to check all apartment and have the heater fixed/repaired. Proof to be submitted by 5/18/2022.
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The temperature at the dining area was not at comfortable level and heaters in residents apartments not working. These pose potential health and personal right risks to persons 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) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4