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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 02/25/2025
Date Signed: 02/26/2025 08:08:47 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
05/23/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240523150242
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: 50DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Glenda Bertucci, Executive DirectorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff did not properly care for resident's pressure injury.
INVESTIGATION FINDINGS:
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On 2/25/2025 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegation above. LPAs met with Executive Director, Glenda Bertucci and informed her of the reason for the visit.

During the course of investigation, LPA G. Luk interviewed 4 residents, 6 staff, witness, and complainant. LPA reviewed and obtained documents including staff list with contact information, admission agreement, care plan, emergency information, care notes, home health information, and discharge documents. Interview with witness revealed that staff used Clorox bleach wipes to clean the area of the pressure injury (buttock area). After reviewing a video of the incident, LPA observed staff grabbed the bleach wipes on the counter to clean R1’s buttock area.
(continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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-20240523150242
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: 02/25/2025
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240523150242
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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...competency to meet their needs.
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Executive Director (ED) agreed to a written plan to address wound care including staff training and submit a copy to CCLD by POC date.
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This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by staff not properly care for resident's pressure injury which poses a potential health and safety risk to the 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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
05/23/2024 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240523150242

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: 50DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Glenda Bertucci, Executive DirectorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Resident sustained a pressure injury while in care.
Staff left resident in wheelchair for an extended period of time.
Staff did not provide resident a clean bed.
Staff did not ensure resident's room was clean and sanitized.
INVESTIGATION FINDINGS:
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On 2/25/2025 at 3:05PM, Licensing Program Analysts (LPAs) G. Luk and P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings regarding the allegations above. LPAs met with Executive Director, Glenda Bertucci and informed her of the reason for the visit.

During the course of investigation, LPA G. Luk interviewed 4 residents, 6 staff, witness, and complainant. LPA reviewed and obtained documents including staff list with contact information, admission agreement, care plan, emergency information, care notes, home health information, and discharge documents.

Resident sustained a pressure injury while in care.
R1’s discharge report dated 10/2/2022 indicated R1 had stage 2 pressure ulcer on buttock area prior to admission to the facility. R1 was receiving home health care.
(continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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-20240523150242
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: 02/25/2025
NARRATIVE
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Staff left resident in wheelchair for an extended period of time.
Interview with staff revealed that R1 can transfer to bed and sometimes need help with transfer. S6 stated that R1 likes being in the wheelchair all the time. Sometimes when S6 put R1 to bed, R1 wants to stay in the wheelchair to watch TV.

Staff did not provide resident a clean bed.
Interview with witness indicated that R1’s bed is not clean and mattress has urine stain. However, LPA toured a few resident’s rooms and observed the beds are clean. Interview with staff revealed that resident’s beddings would be changed when it’s soiled or wet.

Staff did not ensure resident's room was clean and sanitized.
Interview with witness indicated that R1’s room was uncleaned and feces were found under the bed. However, LPA toured a few resident’s rooms and observed resident rooms were cleaned. Interview with residents and staff revealed that resident’s rooms are cleaned once a week. Residents stated they did not have any issue of having the room cleaned.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5