019200509-7-20-2023-15-AS-KHOS-CURRSL-20230816131656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:43:33 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
07/12/2023 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20230712121203

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:	07/20/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Robert Roby, Executive Director		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

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On 7/20/2023 at 10:50am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Robert Roby, Executive Director (ED), and explained the reason for the visit.

During the investigation LPA interviewed ED, Reporting Party (RP), and collected and reviewed records. LPA collected the following for Resident 1 (R1): admission agreement closing invoice, and client/resident personal property and valuables upon entry. LPA also collected a copy of the resident roster, and staff schedule. RP stated during interview the facility was responsible for the broken eyeglasses and R1 should be reimbursed. ED stated during interview that he recalls

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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-20230712121203

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: 07/20/2023

NARRATIVE

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Continued from LIC9099.

having a conversation regarding R1's eyeglasses and receiving an invoice for $14. ED also stated that R1 was sent a closing invoice that refunded him $2872.58, but it doesn't itemize the refunded charges. Record review of admission agreement on page 7 section IV states facility is not responsible for furnishing or paying for eyeglasses, and page 17 section F stated facility is not responsible for the loss of any personal property unless loss or damage was caused by negligence of employees. Based on interviews it was not indicated that staff was responsible of losing the eyeglasses. The eyeglasses were found but they were broken.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC9099 (FAS) - (06/04)

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