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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 11/23/2020
Date Signed: 11/23/2020 03:44:42 PM



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
02/24/2020 and conducted by Evaluator Celia Phomphachanh
COMPLAINT CONTROL NUMBER: 15-AS-20200224090004
FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:KAI YUAN QIANFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 78DATE:
11/23/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joyce Latimer, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not respond to resident's call button in a timely manner.
Staff did not assist resident with her toileting needs in a timely manner.
INVESTIGATION FINDINGS:
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On Monday, November 23, 2020, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility unannounced to deliver findings to the above allegations. LPA spoke with Executive Director, Joyce Latimer via Facetime. Due to the Executive Order Shelter in Place set forth by the Governor until further notice, LPA was not able to deliver findings in person.

During the course of the investigation, LPA conducted interviews with staff, witnesses, and reviewed pertinent documents.

For the allegation staff did not respond to resident’s call button in a timely manner, Reporting Party (RP) stated when RP was at the facility with R1, R1 press the call button and it took about 45 minutes to 1 hour for a staff to come and assist R1.When LPA interviewed S1, S1 stated that staff is required to respond to call button within 15-20 minutes at the latest. S1 is unaware of any situation for a 45-minute wait period for any resident.

Continuation on LIC 9099 C - Page 1 of 2 Complaint Investigation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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 5
Control Number 15-AS-20200224090004
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 UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 11/23/2020
NARRATIVE
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Continuation - Page 2 of 2 Complaint Investigation Report
When LPA interviewed S3, S3 stated that S3 there has been incidents once in a while where residents do have to wait for about an hour due to the need or assistance of prior resident’s service call. When LPA interviewed S4 and S5, both admitted it does take a long period of time to assist residents due to staffing. Both S4 and S5 stated that for a resident who need 2-person assist, there would be no available staff to assist the others. In addition, S4 and S5 stated that there have been multiple occurrences where one staff will provide care to a 2-person assistance resident and it will take longer to go assist another resident. When LPA interviewed 7 witnesses, 4 witnesses stated that they were independent and did not use the call button, 1 witness stated that staff does take a long time, and 2 stated that staff was able to come assist within a timely manner.

When LPA asked S1 for a pendant call log during the time of visit on March 3, 2020 and S1 stated that there has been a system reset due to erroneous messages. On August 19, 2020, LPA contacted S1 for pendant call log, S1 was not able to provide LPA a pendant call log. S1 wrote to LPA via email, “Our call notification system has not changed since your visit several months ago. This system’s primary functionality is to alert our caring staff that a resident requires assistance. A secondary function is that we are able to randomly spot check call response times. This allows us to follow up on anything that might appear outside of our accepted parameters. As the system is set-up, I am not able to print call logs.” On 09/23/2020, S1 provided LPA with current call button for the week of 09/16/2020 to 09/22/2020 but was not able to provide LPA with a log during the complaint period. Therefore, LPA has determined this allegation to be substantiated.



For the allegation, staff did not assist resident with her toileting needs in a timely manner. RP stated when R1 press the pendant call button for assistance for toileting needs, staff did not come assist R1 in a timely manner. Staff took about 45 minutes to 1 hours to assist R1. When LPA interviewed S3, S4, and S5, all staff did admit it does take a long period of time to assist residents. Therefore, this allegation is part of one for the incidents where staff took about 45 minutes to 1 hour to assist resident of toileting needs and R1 did not received assistance within a timely manner. The allegation above coincide with this allegation which it took 45 minutes to 1 hour for a staff to respond to a resident in their apartment for assistance. Therefore, LPA has found this allegation to be substantiated.

Based on LPA interviews conducted, and record reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED.

The following deficiency was observed and cited under California Code of Regulations, Title 22, Division & Chapter, are being cited on the attached LIC 9099D. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with Executive Director, Joyce Latimer. Appeal rights and copy of report sent via email in PDF format.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20200224090004
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 UNION CITY
FACILITY NUMBER: 019200509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/07/2020
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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1. Administrator will ensure there is sufficient staffing for residents on each floor and provide CCL with updated LIC 500 with self-certify review of regulation 80078 by POC date of 12/07/2020.
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Based on interviews and records reviewed, facility provide to respond to resident's call button in a timely manner which poses a potential health and safety risk for residents in care.
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2. Director will submit written plan on how they will ensure residents' call buttons are answered in a timely manner. Submit plan to CCL by POC date.
Type B
12/07/2020
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a) each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment,, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting;..

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Administrator will reveiw regulation 80072 with self certify the understanding and review of Personal Rights regulation and submit to CCL by POC date 12/07/2020.
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This requirement was not met as evidenced by:

Based on interviews and records reviewed, facility did not assist resident with toileting needs on a timely manner which poses a potential health and safety risk for residents 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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/24/2020 and conducted by Evaluator Celia Phomphachanh
COMPLAINT CONTROL NUMBER: 15-AS-20200224090004

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:KAI YUAN QIANFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 78DATE:
11/23/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joyce Latimer, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not feed resident in a timely manner.
INVESTIGATION FINDINGS:
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On Monday, November 23, 2020, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility unannounced to deliver findings to the above allegations. LPA spoke with Executive Director, Joyce Latimer via Facetime. Due to the Executive Order Shelter in Place set forth by the Governor until further notice, LPA was not able to deliver findings in person.

During the course of the investigation, LPA conducted interviews with staff, witnesses, and reviewed pertinent documents.

For the allegation, staff did not feed resident in a timely manner. RP stated that R1 does not make it breakfast on time. When LPA interviewed S1, S1 stated that residents received a copy of menu with breakfast, lunch and dinner time. There is an option to food to be delivered to residents’ room.

Continuation on LIC 9099 C - page 1 of 2 Complaint Investigation Report
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200224090004
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 UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 11/23/2020
NARRATIVE
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Continuation Page 2 of 2 - Complaint Investigation

When LPA interviewed S3, S4 and S5, all stated that there is a time schedule for eating times. In addition, the residents can call to get assistance to get to the dining area. However, residents are aware that assistance during rush period will take time to get assistance to the dining area. LPA reviewed dining periods:

Breakfast period 7:30 AM to 9:00 AM, Breakfast Tray Service: 8:00 AM to 8:30 AM
Lunch period: 11:30 AM to 1:00 PM, Lunch Tray Service: 12:00 Noon to 12:30 PM
Dinner period: 4:30 PM to 6:00 PM, Dinner Tray Service: 5:00 PM to 5:30 PM

Facility provided room service which begins 30 minutes after the meal begins. Therefore, residents can dine in the room, get room service, or eat at the dining period which options are available to all residents.
Based on interviews conducted and records reviewed, LPA found this allegation to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview conducted with Executive Director, Joyce Latimer. Copy of report provide via PDF emailed.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5