019200509-5-4-2023-15-AS-LFOA-CRHTP8-20230504145356

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:54:09 PM

Document Has Been Signed on 05/04/2023 02:54 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 CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	MANDY TAYLOR		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 62	DATE:	05/04/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Robert Roby		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 4, 2023 at approximately 11:25 am, Licensing Program Analyst (LPA) Luisa Fontanilla conducted an unannounced Case Management visit. LPA met with Robert Roby and explained the purpose of the visit. On August 30, 2017, the Department concluded a complaint investigation on a substantiated allegation that the facility did not seek timely medical attention resulting in amputation of a resident’s (R1) right pinky toe. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87465(a)(1) – Incidental Medical and Dental Care. The facility failed to seek timely medical attention for R1’s toe condition which resulted in amputation. Failing to seek timely medical attention posed an immediate health and safety risk to R1. R1 was taken to the hospital and was diagnosed with gangrene of the toe with cellulitis of the foot. According to the Mayo Clinic, “gangrene refers to the death of body tissue due to either a lack of blood flow or a serious bacterial infection. Gangrene commonly affects the extremities, including your toes, fingers, and limbs, but it can also occur in your muscles and internal organs. Your chances of developing gangrene are higher if you an underlying condition that can damage your blood vessels and affect blood flow, such as diabetes or hardened arteries (atherosclerosis).” *continuation on Lic 809C*

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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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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
	VISIT DATE: 05/04/2023

NARRATIVE

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The investigation revealed that on January 11, 2017 and January 12, 2017, R1’s Primary Care Physician ordered the referral for the resident to be brought to a general acute care hospital – wound clinic to be seen. On January 12, 2017, a referral was also issued to have a doctor from the home health care agency come to examine R1’s foot. Facility staff did not follow up with the home health agency to see when the doctor would come to examine R1, and facility staff did not take R1 to the hospital when they noticed the wound was getting worse.

On January 19, 2017, R1 was transported by the facility and admitted to the emergency room at the general acute care hospital. According to medical records, when R1 was admitted to the emergency room, R1’s right pinky toe was found to be “necrotic” and “nearly off of foot.” R1 was diagnosed with gangrene of the right pinky toe. According to the Mayo Clinic, “Gangrene is a dangerous and potentially fatal condition. Treatments for gangrene include surgery to remove dead tissue.” The hospital noted that the wound on R1’s right foot was getting worse, the toe was black, foul smelling, and swelling to the foot with redness up to the calf. On January 23, 2017, R1 underwent amputation of the right pinky toe. On January 24, 2017, pathology findings of the amputated right fifth toe, revealed early acute osteomyelitis. According to Mayo Clinic, osteomyelitis is an infection in a bone…infections can reach a bone by traveling through the bloodstream, spread from nearby tissue, or start in the bone itself if an injury exposes the bone to germs. On January 27, 2017, R1 was discharged from the hospital to a skilled nursing facility.

A Physician’s Report, dated October 20, 2014, indicates that R1 had no history of a skin condition prior to being admitted to the licensee’s care.

***continuation on Lic 809C***

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 05/04/2023

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Based on interviews, record review and observation, the facility staff failed to obtain timely medical attention for R1. The licensee’s failure to seek timely care caused R1 to suffer serious bodily injury which required hospitalization and surgery to amputate the right pinky toe.

At the time of the complaint visit, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty is still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, May 4, 2023 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on August 30, 2017, the amount of the civil penalty today will be $9,500.

A copy of the LIC 421D was given to Robert Roby and originals were signed.

Exit interview was conducted. Appeal Rights was provided. Robert Roby's signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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