015601394-6-2-2022-15-AS-KHOS-CXBK6U-20231106063807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 06/02/2022
Date Signed: 06/02/2022 06:52:31 PM

Unsubstantiated

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
05/25/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220525113548

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: 60	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Lisa Lostica/Senior Business Office Manager		TIME COMPLETED:	06:55 PM

ALLEGATION(S):

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Facility is not providing comfortable temperature for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegation. LPA met with Senior Business Office Manager Lisa Lostica, and informed the purpose of visit.

LPA obtained copies of resident roster and staff schedule. LPA interviewed staff (S1 and S2) and residents (R1, R2, R3, R4 and R5). S1 indicated the family members bring electric fans to the residents and facility provide to resident who ask for it. S2 stated the facility has centralized air conditioning only in the common areas and hallways, and residents' rooms have heaters but no air conditioning units. S2 stated no residents complained about their rooms being hot and/or uncomfortable.

...continued next page (9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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-20220525113548

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: 06/02/2022

NARRATIVE

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All five residents confirmed S2's statement that their rooms do not have air conditioning unit. Four out of five residents indicated they don't have problem with the temperature in their rooms. R3 stated the temperature in R3's room would at times be hot and uncomfortable but R3 has electric fan to cool off the room.

LPA tested the temperature in the common area and in one of the resident's room, and measured at 72.9 and 81.9 degrees Fahrenheit respectively.

Based on all the information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided to Lisa Lostica.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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