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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 10/24/2024
Date Signed: 10/24/2024 10:29:14 AM

Document Has Been Signed on 10/24/2024 10:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR/
DIRECTOR:		BERTUCCI, GLENDA TFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 47DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Glenda Bertucci, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
NARRATIVE
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On 10/24/24 at approximately 09:35 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a case management visit pertaining to a letter received by the Oakland CCLD ASC Regional Office from the facility. LPA met with Executive Director (ED), Glenda Bertucci and explained the purpose of the visit.

On July 11, 2024, the Oakland CCLD ASC Regional Office received from the facility a letter of intent to de-license the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCLD and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents.

On 10/16/24 LPM Jeremy Fong and on 10/24/24 LPA J. Clancy-Czuleger and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.

Harpreet HumpalTELEPHONE: (510) 285-3928
Jill Clancy-CzulegerTELEPHONE: 510-286-4201
DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 10:29 AM - 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
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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2024
Section Cited
CCR
87208

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“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval."
This requirement is not met as evidenced by:
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By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement. The facility also agree to not admit any more resident to the 55+ floor until they have received approval of their new plan of operations
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Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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