015601394-9-18-2024-15-AS-KHOS-D9FQM6-20240925121702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:22:19 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
08/22/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230822145539

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: 43	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Glenda Bertucci, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not assist resident in feeding.
Resident developed pressure injury while in care.

INVESTIGATION FINDINGS:

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On 9/18/2024 at 9:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with Executive Director, Glenda Bertucci and explained the purpose of the visit.

During the investigation, LPA interviewed 4 residents, 5 staff, and complainants. LPA reviewed and obtained documents including staff list with contact information, LIC500, physician's report, preplacement appraisal, care plan, emergency information, care notes, hospice information, outside agency documentation, meal tracker, and discharge documents.

Staff did not assist resident in feeding.
R1's physician's report dated 7/31/2023 indicated that R1 is unable to feed self. However, R1's assessments dated 1/25/2023 and 8/26/2023 revealed that care for meals was independent. Interview with staff revealed that R1 can feed independently.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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-20230822145539

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: 09/18/2024

NARRATIVE

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Resident developed pressure injury while in care.
R1's physician's report dated 7/31/2023 revealed that R1 has a history of skin condition or breakdown. R1 has home health that would assist with R1's wound care. Outside agency documentation indicated that a nurse have provided wound care for R1. Interview with staff revealed that R1 was repositioned every 1-2 hours.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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