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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:21:47 PM


Document Has Been Signed on 01/18/2024 01:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 46DATE:
01/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adiam Welday, Executive DirectorTIME COMPLETED:
01:40 PM
NARRATIVE
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On 01/18/2024 at 12:00pm Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit to follow-up on a death report received by Community Care Licensing that was faxed on 11/10/2023. LPA met with Executive Director, Adiam Welday and explained the purpose of the visit.

R1 passed away on 11/02/2023 with an unknown cause of death. Administrator stated that R1 had episodes of collapsing while R1 was with the family. R1 stated that the family is the one that reported the collapsing per the Death Report. Administrator stated that no one at the facility witnessed the collapsing.

During today's visit LPA obtained additional information pertaining to R1's death:
  1. Physician's Report
  2. Resident Assessment
  3. Face Sheet
  4. Assessment for Medication Self-Management
  5. Needs and Services Plan
  6. Internal Incident Report


LIC809 Continued....
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/18/2024 01:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured
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Administrator will go over reporting requirements and submit a self certification of understanding of reporting requirements.
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This requirement is not met evidenced by:

Based on record review, the Administrator did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.
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Administrator shall submit self-certification to CCLD by POC due date.

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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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING SAN LEANDRO
FACILITY NUMBER: 015601394
VISIT DATE: 01/18/2024
NARRATIVE
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LIC809-C Continued...


LPA requested from facility a copy of R1's death certificate. LPA was informed by Administrator that they phoned the family and left a message requesting the death certificate.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3