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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 02/13/2023
Date Signed: 02/13/2023 06:34:20 PM


Document Has Been Signed on 02/13/2023 06:34 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 UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:MANDY TAYLORFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 67DATE:
02/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Robert 'Bob' Roby/Business Office ManagerTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day, February 13, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230209091605). LPA met with Business Office Manager Robert 'Rob' Roby, and informed the reason for visit. LPA also met with Resident Services Director Shanina Mason

LPA toured the facility including but not limited to common areas, dining rooms, kitchen, medication rooms, activity rooms/areas, and shared bathrooms and common bathrooms on the first and second floors. LPA observed the medication rooms open and attended by med-techs. LPA observed the storage in Memory Care Unit and the salon in Assisted Living Unit locked. LPA randomly selected for inspection a total of 5 resident rooms on the first and second floors. LPA tested the water temperature in 2 of the bathrooms on the first floor.

LPA observed the following:
1. Hot water temperature at 80 degrees Fahrenheit.
2. Unlocked Tylenol and Clobetasol cream in resident's (R1) room. Review of LIC602A Physician's Report showed R1 can not store and administer own prescription, non-prescription and PRN medications.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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 02/13/2023 06:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2023
Section Cited

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87303 Maintenance and Operation
(e)(2) Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Corrected.
Business Office Manager called the plumbing company while LPA is at the facility. Water temperature was adjusted to 105. 2 degrees Fahrenheit.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above for water temperature tested and measured at 80 degrees Fahrenheit which poses ummediate safety & personal right risks to persons in care.
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Type A
02/14/2023
Section Cited

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87465 Incidental Medical and Dental Care (h):(1) Medications shall be centrally stored ....:(B)Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed
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Staff locked the items immediately.
In addition, an in-service training to be conducted, and proof with attendees signatures to be submitted by 2/14/23.
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-This requirement is not met as evidenced by:
-Based on inspection, the licensee did not comply with the section above for R1's medications unlocked which pose immediate health risk to person 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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