015601394-3-15-2022-15-AS-KHOS-CKBLUP-20221018090416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:19:06 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
03/08/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220308155655

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: 59	DATE:	03/15/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gilbert Castro, Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Facility did not regularly observe residents for change in condition

INVESTIGATION FINDINGS:

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On 3/15/2022 Licensing Program Analysts (LPAs) L. Ibo and K. Nguyen arrived unannounced to in order to meet the 10-day requirement for notification of the above allegation. LPAs met with Gilbert Castro; LPAs explained the purpose of the visit.

During the investigation, LPAs interviewed 3 staff and gathered the following documents but not limited to; LIC610E, resident roster, staff roster & incident reports. Administrator admitted that on 3/6/2022 there was a power outage from 7:00pm – 7:04pm, the call button system was disconnected until around 10:00AM 3/7/2022. Administrator instructed staff to constantly check all residents and provide bells to residents, staff then provided bells to residents that require higher level of care. Staff stated that residents was constantly check during call button system was disconnected.

LPAs could not interview reporting party (RP) since RP requested to be anonymous.
…Continued to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

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-20220308155655

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: 03/15/2022

NARRATIVE

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Although the allegation may have happened or are valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation are unsubstantiated.

No deficiencies cited. Technical assistance provided.

Exit interview conducted and a copy of this report provided to administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022

LIC9099 (FAS) - (06/04)

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