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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 12/11/2023
Date Signed: 12/11/2023 01:45:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/02/2023 and conducted by Evaluator Paris Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231002093949
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:
12/11/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Robert Roby, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has mold
INVESTIGATION FINDINGS:
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On 12/11/2023 at 11:00 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegation. LPA met with Executive Director Robert Roby and explain the purpose of the visit

During the course of the investigation, LPA toured the facility and interviewed staff and residents, and obtained resident roster with family contact information. LPA also reviewed documentation regarding mold inspects done at facilty.


Report continues on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/02/2023 and conducted by Evaluator Paris Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231002093949

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:
12/11/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Robert Roby, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide a safe and comfortable environment
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/11/2023 at 11:00 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. LPA met with Executive Director Robert Roby and explain the purpose of the visit

During the course of the investigation, LPA toured the facility and interviewed staff and residents, and obtained resident roster with family contact information. LPA also reviewed documentation regarding mold inspects done at facilty.

Report continues on 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20231002093949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 12/11/2023
NARRATIVE
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It was alleged that Staff did not provide a safe and comfortable environment

Based on observations, LPA observed the facility to be safe and comfortable for residents. Based on interviews with residents (R1, R2 and R3) residents felt that they were safe and comfortable, residents stated they have had no issues with staff and that staff are very nice. Based on interviews with staff (S1) residents have not expressed feeling unsafe or uncomfortable. S1 stated that they have not observed a resident being treated unwell and that staff ensure to take care of the residents.

Based on LPA observations, interviews, 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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20231002093949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 12/11/2023
NARRATIVE
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It was alleged that Facility has mold

Based on interview with Maintenance Manager (MM), if mold/mildew was present and reported to facility staff it would be treated in house. MM stated that they would inspect the area, relocate the resident residing in area and treat it with cleaners such as bleach. Based on documentation review, there was evidence of mold located in a resident’s apartment and mold treatment was required. Based on interviews with staff (S3 and S4) mold has been observed in various apartment’s in residents AC units and closets by staff and residents residing. S3 stated that they have reported their observations to facility management and noticed AC units were replaced recently. S3 believes mold is throughout the facility still despite facility management changing AC units.

Based on LPAs interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20231002093949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...


This requirement is not met as evidenced by:
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Administrator will submit their mold treatment plan and prevention plan to ensure no mold outbreak in the future to CCL by POC date
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 Based on interviews and documentation review the facility has/had mold in various resident apartments which poses/posed an immediate/potential Health, Safety or Personal Rights risk to persons 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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5