015601394-4-18-2022-15-AS-YFLS-CEPW4D-20220523165723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:33:23 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
06/04/2020 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200604135835

FACILITY NAME:	PACIFICA SENIOR LIVING SAN LEANDRO		FACILITY NUMBER:	015601394
ADMINISTRATOR:	BETH JENNINGS WILLIAMS		FACILITY TYPE:	740
ADDRESS:	348 W JUANA AVE		TELEPHONE:	(510) 357-1691
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	90	CENSUS: 59	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Lisa Lostica, Senior Business Office Manager		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Personal Rights - Resident sustained a fracture while in care.
Facility did not provide resident’s representative with proper notification of eviction.

INVESTIGATION FINDINGS:

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On 4/18/2022, Licensing Program Analyst (LPA) C. Lin arrived unannounced to deliver findings for the above allegations. LPA met with the Senior Business Office Manager, Lisa Lostica and explained the purpose of the visit.

Allegation: Resident sustained a fracture while in care
During investigation, the Department conducted interviews and obtained records. On 02/26/2020, Resident 1 (R1) fell in the bathroom which resulted in a fractured spine. Prior to the fall, facility documents and statements made during interviews with staff state that R1 had fallen multiple times between 09/2019 and 02/2020. There is no documentation to show that the facility conducted a reassessment of R1 or updated R1’s Appraisal Needs and Services Plan.

Continue on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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 4

Control Number 15-AS-20200604135835

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: 04/18/2022

NARRATIVE

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Residents are equipped with a call button that they wear on their necks, which when pressed the staff are alerted. R1 would not use the call button. Staff were aware that R1 would not use call button, rather would transfer alone. According to staff interviews, they were not sure if R1 was able to comprehend the purpose of the call button. R1 was diagnosed with Dementia on 02/07/2017. However, staff interviewed state they were unaware of R1’s Dementia diagnosis. The above allegation is substantiated.

A $500 immediate civil penalty is assessed on this day for violation which resulted to the injury of R1. Civil penalty determination related to serious bodily injury is pending.

Allegation: Facility did not provide resident’s representative with proper notification of eviction
On 3/2/2022, LPA Luisa Fontanilla interviewed Lisa Lostica, Business Office Manager (BOM). BOM states there was no eviction letter issued to R1. R1’s change in condition prohibits facility from taking R1 back. Based on records reviewed, facility did not take R1 back due to R1 needing two persons to assist, R1 not participating in caregiver ADL assistance and that R1 was diagnosed with Dementia. And that the facility is not a dementia facility. However, facility failed to provide LPA reassessment record.
On 3/15/22, LPA L. Fontanilla reviewed R1’s Admission Agreement signed by R1’s responsible person on 3/9/2013. LPA observed Xlll Basic Services Section S states “Dementia Services. The Community features a specialized Memory Care Program that is designed for those Residents with Alzheimer’s disease or related Dementias………” This allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099 D.

Exit interview conducted with Senior Business Office Manager. LIC9099D, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/04/2020 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200604135835

FACILITY NAME:	PACIFICA SENIOR LIVING SAN LEANDRO		FACILITY NUMBER:	015601394
ADMINISTRATOR:	BETH JENNINGS WILLIAMS		FACILITY TYPE:	740
ADDRESS:	348 W JUANA AVE		TELEPHONE:	(510) 357-1691
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	90	CENSUS: 59	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Lisa Lostica, Senior Business Office Manager		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility did not provide resident's representative with proper notification of rate increases.

INVESTIGATION FINDINGS:

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On 3/2/2022, LPA L. Fontanilla interviewed BOM who states that all rent increase letters are generated and sent out to family/responsible persons by the facility’s home office except for the increase in level of care. BOM states if there is increase in level of care, BOM gets a copy of the signed Reassessment Form and enters the increase in the system and added to the resident’s bill.
BOM provided LPA a copy of the notice of rent increase dated 7/25/2019 addressed to R1’s responsible person. However, the letter does not show the responsible person’s signature. Facility has no record that the notice was received by responsible person.

The above allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20200604135835

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: 04/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/19/2022 Section Cited CCR 87705(c)(5)(a)	1 2 3 4 5 6 7	87705(c) (5) (A) Care of Persons with Dementia (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.	1 2 3 4 5 6 7	1. By POC date, Administrator will send to CCL schedule of staff training on Observation of Residents. Proof of training will be submitted to CCL by POC date. 2. A Non- Compliance Conference (NCC) will be scheduled to discuss additional plans of correction. 3. A $500 civil penalty is assessed on this day for violation which resulted to the injury of R1. 4. Civil penalty determination related to serious bodily injury is pending.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on investigation conducted by the Department, R1 had fallen multiple times between 9/2019 and 2/2020. There is no documentation to show that the facility conducted a reassessment of R1. On 2/26/2020, R1 fell in the bathroom which resulted in a fractured spine. Medical records show R1 diagnosed with Dementia on 02/07/2017.	8 9 10 11 12 13 14	A $500 immediate civil penalty is assessed today.
Type B 04/25/2022 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	87224 (a) (4) Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.	1 2 3 4 5 6 7	By POC date, Administrator will review regulation, and submit a self-certification of understanding to CCL.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and records review, facility failed to issue R1 a 30-day notice of eviction. Facility refused to take back R1 when R1 was ready for discharge back to the facility from the skilled nursing facility (SNF).	8 9 10 11 12 13 14

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) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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