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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:46:48 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
08/26/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210826091031
FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 67DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Robert Roby, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Resident sustained three stage 2 pressure injuries while in care
Staff failed to administer resident’s medication as prescribed
INVESTIGATION FINDINGS:
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On 2/2/2023 starting at 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to deliver findings for the above allegations. LPAs met with Assistant Executive Director, Robert Roby and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, and interviewed staff and residents. It was alleged resident sustained three stage 2 pressure injuries while in care. On 01/26/2023, LPA L. Fontanilla reviewed R1’s hospice notes and observed the following: On 08/09/2021, hospice nurse wrote "Stage 2 coccyx pressure ulcer 0.4cm x 0.2cm…”; and on 04/23/2021, Doctor’s order stating “wound care R hip Stage 1 pressure sore 1.5cm x 1.5 cm…”. Based on records reviewed, R1 sustained one Stage 2 pressure injury in the coccyx and one Stage 1 pressure injury on right hip.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
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
08/26/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210826091031

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Robert Roby, Assistant Executive DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Resident lost 25lbs while in care
Resident was left in wet diapers for extended periods of time
Staff failed to meet resident's hygiene needs
Resident was not adequately fed while in care
INVESTIGATION FINDINGS:
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On 2/2/2023 starting at 9:50 AM, Licensing Program Analysts (LPAs) L. Francisco and P. Watson arrived unannounced to deliver findings for the above allegations. LPAs met with Assistant Executive Director, Robert Roby and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, and interviewed staff and residents. It was alleged resident lost 25lbs while in care. Based on record review of weight records, resident lost 7.4 lbs on 7/6/21 and gained 6.4 lbs on 8/3/2021. However, during an interview with 1 of 5 staff, LPA discovered that there are two different type of weight scales used, and one of the scale was not accurate.

REPORT CONTINUES ON 9099
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210826091031
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: 02/02/2023
NARRATIVE
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It was alleged resident was left in wet diapers for extended periods of time and staff failed to meet resident's hygiene needs. However, based on interview with 3 of 5 staff, R1's hospice agency conducts visit daily and assist R1 with toileting and dressing. S4 and S5 stated that two rounds are conducted per shift. LPA discovered during an interview with S4 and S5 that residents who are under hospice are also changed as needed by caregivers.

It was alleged resident was not adequately fed while in care. On 1/16/2023, LPA L. Fontanilla reviewed R1’s hospice notes from April 2021 to August 2021. Based on records reviewed, R1 had a fair appetite. R1 preferred to pick own food and refused assistance from staff with meals. Notes also indicate that R1 was consuming 30-50% 3 times a day.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Assistant Executive Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20210826091031
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: 02/02/2023
NARRATIVE
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It was alleged staff failed to administer resident’s medication as prescribed. On 01/25/2023, LPA L. Fontanilla obtained and reviewed R1’s Medication Administration Record (MAR) for 2019-2020 and Centrally Stored Medication and Destruction Record (CSMDR). R1 had an order for Donepezil (Aricept) 10 mg 1 tablet by mouth daily in the morning and ½ tablet (25mg) by mouth after lunch. A review of R1’s MAR for 5/23/2021-6/22/2021 shows an encircled initial of the staff person giving medication from 5/30/2021 till 6/22/2021. Upon verification made by LPA L. Fontanilla with Robert Roby, the code facility uses if a resident refuses to take medication is the staff person’s initial with a circle around it. Based on records reviewed, R1 did not get Donepezil from 5/20/2021-6/22/2021.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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. Appeal Rights and a copy of this report provided to Assistant Executive Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20210826091031
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: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited
HSC
1569.269(a)(10)
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§1569.269(a)(10) Enumerated rights; severability
(10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

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By POC date, Administrator agrees to review Personal Rights with all caregivers and submit proof of training to CCL.
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This requirement is not met as evidenced by: Based on records review, Licensee did not comply with the regulation cited above. R1 sustained one Stage 2 coccyx pressure ulcer and one Stage 1 pressure injury on right hip which poses an immediate health and safety risk to residents in care.
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Type A
02/03/2023
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility.....(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications….
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By POC date, Administrator agrees to review Incidental Medical and Dental care regulation with all caregivers and submit proof of training to CCL.
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This requirement is not met as evidenced by: Based on records review, the Licensee did not comply with the regulations cited above when R1 was not given Donepezil from 5/30/2021 to 6/22/2021 which poses an immediate health and safety risk 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5