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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 08/13/2021
Date Signed: 08/13/2021 12:16:57 PM

Document Has Been Signed on 08/13/2021 12:16 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
CCLD Regional Office, 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: DATE:
08/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Gilbert Castro & Karren Malad TIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) L. Ibo conducted a case management visit on the AWOL incident report submitted by S2 , LPA meet with Executive Director Gilbert Castro and informed him the purpose of the visit.

Report indicated that around 2:00 AM on July 22, 2021, staffs went on their rounds and found R1 was not in the room, fire exit door was noted open. Staffs called Executive Director Gilbert, S2, and R1’s family, 911 was also called for assistance. At around 5:00 AM police found R1 walking on the street and was brought back to the facility.

LPA conducted interview. LPA requested for the following documents from Gilbert C. , admission agreement , LIC601, LIC602A, Pre-placement appraisal and incident reports pertaining for R1.

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 penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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 08/13/2021 12:16 PM - It Cannot Be Edited


Created By: Leslie Ibo On 08/13/2021 at 11:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations....
This requirement was not met as evidence by:
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Adminitrator will submit a plan to CCL office on how to address the admission process of residents with possible or diagnosis of Dementia. Plan need to be submitted on or before POC date.
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Based on LPA's interview and records review , resident was diagnosed with DEMENTIA, based on interview, facility is not designed to have dementia residents in care, facility did not comply with the section cited above which poses an immediate health and safety 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 Humpal
LICENSING EVALUATOR NAME:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021


LIC809 (FAS) - (06/04)
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