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

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:59:43 PM

Unsubstantiated

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):

1
2
3
4
5
6
7
8
9

Resident was left in soiled clothing for extended period of time
Staff do not ensure personal needs are being met for resident in care
Staff do not ensure food is served at appropriate temperatures to resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

On 3/22/2023, LPA interviewed 4 staff and 3 residents. Resident 3 (R3) states that R3 eats all meals in the room. And that staff would deliver R3’s foods and staff would warm foods for R3, if needed. R3 added staff come to assist R3 and that everything is good.

Staff interviewed state that all residents are encouraged to eat their meals in the dining room. For residents who prefer to eat meals in their rooms, staff deliver food to the rooms. Staff interviewed state R1 is able to communicate needs with staff. And R1 would eat breakfast and lunch in the dining room. However, for dinner R1 prefers to eat in the room. Staff state that R1 would call staff if R1 needed help.

*** continuation on Lic 9099c***

Unsubstantiated

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)

Page: 1 of 2

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
	VISIT DATE: 05/04/2023

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
26
27
28
29
30
31
32

Memory Care Director and staff interviewed state residents who are incontinent get changed every 1-2 hours. They also state they are aware which residents are incontinent and needed to be changed regularly.

Staff interviewed also state that they make sure each resident wears clean clothes all the time. And that they check on residents' clothes especially after meals for food spills.

Memory Care Director states R1 moved out of the facility a few days prior to LPA visit due to the increase in level of care fees.

On 5/4/2023, LPA interviewed R4, R5 and R6. R6 states that staff are good. R6 added that staff come to assist if needed. LPA attempted to interview R4 and R5 . Due to dementia diagnosis, LPA was unable to interview R4 and R5.

Based on interviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 2