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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 11/28/2023
Date Signed: 11/28/2023 05:31:16 PM


Document Has Been Signed on 11/28/2023 05:31 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 CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:ROBY, ROBERT BFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 64DATE:
11/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Robert 'Rob' Roby/Executive Director and
Shenina Robinson-Mason/Assisted Living Director 		TIME COMPLETED:
05:40 PM
NARRATIVE
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On this day, November 28, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20231122143232). LPA met with Executive Director (ED) Robert 'Rob' Roby and
Assisted Living Director Shenina Robinson-Mason.

LPA toured the facility including but not limited to common areas, dining rooms, medication room, activity rooms/areas, and bathrooms on the first and second floors. LPA observed the medication room open and attended by a med-tech. LPA randomly selected for inspection a total of 5 resident rooms on the first and second floors.

During review of 4 residents records, LPA observed no Death Report and Unusual Incident Report (UIR) for 1 of the residents.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies were discussed with ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 05:31 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured
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Corrected.
Executive Director provided copy of Death Report while LPA is at the facility.
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-This requirement is not met evidenced by:

-Based on record review, the licensee did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.
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Type B
12/12/2023
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events.....(D) Any incident which threatens the welfare, safety or ........
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Corrected.
Executive Director provided copy of incident reportt while LPA is at the facility.
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......health of any resident......
-This requirement is not met evidenced by:
-Based on record review, the licensee did not comply with the section above for not submitting an incident report within 7 days which posed potential personal rights risk to person in care.
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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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2