015601394-10-7-2021-15-AS-KHOS-C86MFC-20211026093407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:33:12 PM

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
05/18/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20200518165414

FACILITY NAME:	PACIFICA SENIOR LIVING SAN LEANDRO		FACILITY NUMBER:	015601394
ADMINISTRATOR:	BETH JENNINGS WILLIAMS		FACILITY TYPE:	740
ADDRESS:	348 W JUANA AVE		TELEPHONE:	(510) 357-1691
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	90	CENSUS: 49	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gilbert Castro		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident sustained fracture while in care
Residents diapers not changed in a timely manner resulting in a wound
Unlawful eviction
Staff mishandling residents medication
Staff not refilling residents medication prescription
Staff not maintaining residents hygiene and room
Staff not responding to residents call button
Staff not providing adequate food service for resident

INVESTIGATION FINDINGS:

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On 10/7/2021 Licensing Program Analyst (LPA) L.Ibo arrived unannounced to conduct a complaint investigation regarding the above allegations. LPA met with Executive Director, Gerald Castro and explained the purpose of the visit.

During the course of investigation, LPA collected and reviewed the following documents but not limited to resident roster, LIC500 and physician’s report.

Continued to LIC9009C….

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20200518165414

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: 10/07/2021

NARRATIVE

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Based on the information gathered, there was no evidence that R1 had fractured while in care. During records review on February 29,2020 a 30-days’ notice was given by R1 to terminate contract from the facility.

Based on interview and records review staff refilled medication on timely manner, staff sent fax to R1’s doctor for prescription refills. Facility has once a week housekeeping schedule to keep facility clean and laundry schedule is done during housekeeping schedule.

Based on interview staff has maximum 7-10 mins. to respond to any call button or resident page, the caregiver will check the resident if the first and second call was not answered the medtech will check resident.

Based on interview and records review, during the start of pandemic the staff would deliver food to all resident, staff delivered breakfast, lunch and dinner, and other food options is available upon request.

No deficiencies cited during this visit.

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

Exit interview conducted with Executive Director and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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