015601394-10-20-2023-15-AS-HHUL-CXKPX6-20231114104147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:05:46 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
10/13/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20231013125437

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: 47	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maria Locstica, Business Office Manager		TIME COMPLETED:	03:14 PM

ALLEGATION(S):

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Refused to allow resident to come back to the facility

INVESTIGATION FINDINGS:

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On 10/20/2023 at 1:50PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Maria Locstica, Business Office Manager.

During the initial 10-day complaint visit. LPA interviewed staff, collected the following documents: Resident Roster, Personnel Report, Pacifica Policy, Clinical Summary for R1, Corespondence with staff medical team,

S1stated that R1left the facility to go to the hospital after having pain on her ankle. The hospital discharged R1 to a Skilled Nursing Facility (SNF) for infection in her wound. The facility was informed by R1s daughter that they could no longer stay at the SNF for insurance reasons and they were looking to come back to the facility. The facility staff looked into the kind of wound R1 had and what stage it was at. They were informed that it was not stageable.
Continued on 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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-20231013125437

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: 10/20/2023

NARRATIVE

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...Continued from 9099
The facility informed R1 and family that they are not a medical facility and are unable to care for the wounds of this seriousness. The facility said that they could wait for the wound to heal for R1 return or to obtain hospice services to care for the wound.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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