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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 07/19/2023
Date Signed: 07/19/2023 05:12:35 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
05/26/2022 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220526161218
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: 58DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Marissa BaldomeroTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not prevent resident from wandering away from the facility
Staff are mismanaging resident's medication

INVESTIGATION FINDINGS:
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On 7/19/2023, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding on the above allegation. LPA met with Marissa Baldomero, Memory Care Director.

During the course of investigation, then LPA Lizette Francisco initiated 10-day investigation and obtained records on 6/2/2022. On 3/7/2023, this complaint was reassigned to LPA Luisa Fontanilla. On 6/27/2023, LPA Fontanilla obtained additional records for Resident 1 (R1) as follows: Emergency Information and Identification, Reassessment, Physician’s Report, Medication Administration Record (MAR), Centrally Stored Medication Record (CSMR) and Elopement Policy.

Based on records review conducted, R1’s Physician’s Report (PR) indicates R1 has diagnosis of Dementia. The PR also indicates R1 is confused/disoriented, has wandering behavior and unable to leave facility unassisted.
continuation on Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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
Control Number 15-AS-20220526161218
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: 07/19/2023
NARRATIVE
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On 5/23/2022, R1 wandered away from the facility. Based on the call record provided by RP, RP was informed about the incident at around 6:33 pm. RP was told by facility that R1 was observed missing at around 4:45 pm. At around 6:38 pm, RP states that a friend texted RP about R1 spotted around Niles area of Fremont which is approximately 4.4 miles away from the facility and has a walking time of approximately 1hr and 36 minutes. At around 7:15 pm, RP found R1 near the corner of Mission Blvd and Walnut Avenue in Fremont.

A copy of Union City Police Department Everbridge Nixles missing person report was obtained and indicates that the incident was entered on 5/23/2022 at 7:41pm.

A review of facility’s three internal incident reports confirm that R1 wandered away from the facility on May 23, 2022.

Staff are mismanaging resident's medication

LPA L. Fontanilla obtained and reviewed R1’s April - May 2022 Medication Administration Record (MAR). April 2022 MAR indicates R1 was on Donepezil from April 22-30. For the month of May, R1 was given the medicine on May 3,4,7,8,9,11-14 for a total of (9) days only.

Based on records review conducted, the above allegations are substantiated.

Based on record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations Title 22 are being cited on the attached Lic 9099D

Exit interview was conducted with Director and Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220526161218
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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2023
Section Cited
HSC
1569.269(a)(10)
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(a) Residents of residential care facilities for the elderly shall have all of the following rights:
(10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidenced by:
This requirement is not met as evidenced by:
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Director will review records of all residents who have wandering behavior and update needs and services plan to address exit seeking behavior. A copy of the updated plan will be submitted to CCL by POC date.
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On May 23, 2022, R1 wandered out of the building. R1 has dementia and medical records indicate R1 is not allowed to leave the facility unassisted.
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Type B
07/28/2023
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed....
(4) The licensee shall assist residents with self-administered medications as needed.
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MCD will review all MARs and medications to ensure all residents are taking medications accordingly and submit self certification of completion to CCL by POC date.
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This requirement is not met as evidenced by:
Based on review of MAR for May 2022, R1 was given Donepezil for only 9 days.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
05/26/2022 and conducted by Evaluator Luisa Fontanilla
COMPLAINT CONTROL NUMBER: 15-AS-20220526161218

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: 58DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Marissa BaldomeroTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not meet resident's laundry needs
Residents room has pests
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrrived unannounced to deliver findings on the above allegations and met with Memory Care Director (MCD) Marissa Baldomero. LPA explained to MCD the purpose of the visit.

Staff did not meet resident's laundry needs

During the course of investigation, LPA interviewed staff and reviewed records. Based on interview conducted with Memory Care Director (MCD), all residents in the Memory Care unit receive laundry services as often as needed especially the incontinent residents.
A review of R1’s assessment dated 2/28/2022 indicates R1 has 0 point Independent with laundry needs. Laundry schedule obtained by LPA indicates R1 has Friday as laundry day.

continuation on Lic 9099C


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220526161218
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: 07/19/2023
NARRATIVE
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Resident’s room has pests

During the course of investigation, LPA interviewed Robert Roby. He states the facility has a contract with Ecolab Pest Control. On 7/19/2023, LPA inspected four rooms in the Memory Care Unit and did not observe any pests in the rooms. MCD denied seeing any pests in any of the rooms in the Memory Care Unit.

Based on observation and interviews conducted, the above allegations are unsubstantiated.
Although the allegation 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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5