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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:48:28 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
08/26/2024 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20240826122412
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: 47DATE:
10/28/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Glinda Bertucci, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide sufficient notice to resident's authorized person of change in use
INVESTIGATION FINDINGS:
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On 10/28/2024 at 3:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived to deliver amended findings and report for visit conducted on 9/05/24 in regard to the allegation above. LPA met with Glinda Bertucci, Executive Director and explained the purpose of the visit.

S1 provided LPA with a copy of a letter dated July 17,2024 that was given to residents and families regarding the facility’s plan to relocate the 3rd floor residents to other floors of the facility and de-license the 3rd floor. LPA reviewed the letter and found that the letter was not in compliance with CCL regulations. The letter did not contain many of the required regulatory components for a notice of eviction.

Based on LPA interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20240826122412
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: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
87224(5)(A)
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87224 Eviction Procedures
(5) Change of use of the facility.
(A)The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.
1. In addition to written notice to quit requirements specified in Section 87224(d),...notice shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the HSC.
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ADM to submit 60-day eviction letter that meets regulations to LPA, residents, and families by POC date.
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This requirement is not met as evidenced by the 60-day notice letter given to residents was not in compliance with regulation 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC9099 (FAS) - (06/04)
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