015601394-3-20-2024-15-AS-BFOG-D5HTXV-20240522150748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 03/20/2024
Date Signed: 03/20/2024 05:48:35 PM

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
03/11/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20240311152642

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: 42	DATE:	03/20/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jeralyn May/Interim Administrator and Lisa Lostica/Senior Business Office Manager		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Licensee is not assuring the provision of laundry services for residents' clothing without additional cost.

INVESTIGATION FINDINGS:

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At 11:30 a.m., on this day, March 20, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with interim Administrator Jerayn May and Senior Business Office Manager Lisa Lostica, and informed the reason for visit.

During investigation. LPA obtaineed copies of resident roster, LIC500 Personnel Report. From the resident roster, LPA selected 3 residents for file review and obtained copies of Admission Agreement, Resident Services Plan, Care and Services Plan and record of service for personal laundry. LPA also obtained copy of notification dated December 20, 2023 pertaining to laundry service fee for personal laundry, and conducted interviews.

.........continued on 9099C

Substantiated

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: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

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-20240311152642

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: 03/20/2024

NARRATIVE

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Jeralyn May stated that a fee for residents' personal laundry is being charge effective March 1, 2024, and the 60-day notification was provided to all resident which was confirmed with copy of the notification obtained by LPA. Copies of records for personal laundry with corresponding charges were obtained by LPA on this same day.

Staff (S1, S2 and S3) stated residents are started to be charge for laundry of clothing starting March 2024.

Two of the 3 residents interviewed stated they were not charge before and confirmed they are being charge for laundry of their clothing effective March 2024.

Based on LPA review of records and interviews, the preponderance standard has been met, therefore the allegation of "Licensee is not assuring the provision of laundry services for residents' clothing without additional cost" is substantiated.

Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the Jeralyn May.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240311152642

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: 03/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/03/2024 Section Cited CCR 87307(a)(30)(F)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services: (a).....The following provisions shall apply: (3).....if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(F) Basic laundry service (washing, drying, and ironing of personal clothing).	1 2 3 4 5 6 7	Administrator to do the following, and submit proof by 4/03/24: 1. Stop charging the residents for personal laundry. 2. Notify the residents regarding item # 1. 3. Revise the Admission Agreement pertaining to laundry service.
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above for charging the residents for laundry of personal clothing which poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024

LIC9099 (FAS) - (06/04)

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