019200509-5-4-2023-15-AS-YFLS-CRVRL9-20230516130647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:58:01 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
02/24/2023 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230224095354

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
		UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Robert Roby		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Resident developed an open sore while in care

INVESTIGATION FINDINGS:

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On this day at approximately 2pm , Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver findings on the above allegation and met with Robert Roby and explained the purpose of the visit.

During the course of investigation, LPA obtained records and interviewed staff on 3/22/2023. On April 4, 2023, LPA interviewed Home Health Nurse who provided wound treatment to Resident 1 (R1).

Based on records review and interviews conducted, R1 developed Stage 2 pressure injuries on left posterior thigh and Stage 1 pressure injury on coccyx. A home health agency was contacted to provide wound treatment to R1.

Based on information obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached Lic 9099D.

Substantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230224095354

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: 05/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/05/2023 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 Enumerated rights: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	R1 has moved out of the facility. Director will submit a plan to CCL on how to prevent residents from developing pressure injuries. Plan needs to be submitted to CCL by 5/8/2023.
	8 9 10 11 12 13 14	Based on records review and interviews conducted, the licensee did not comply with the section above when R1 developed Stage 2 pressure injuries on left posterior thigh and Stage 1 pressure injury on coccyx which posed an immediate health	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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