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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 07/25/2024
Date Signed: 07/25/2024 03:33:36 PM


Document Has Been Signed on 07/25/2024 03:33 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: 58DATE:
07/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jeralyn May, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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While LPA K. Nguyen was at the facility for a one annual inspection, the following deficiency were observed.

After touring the memory care unit, LPA observed residents where being lock inside their room. In memory care unit there is a door that is lock cannot open without the key. That door led to the resident door that is looked as well. LPA observed that the resident was being locked inside, while still eating breakfast.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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 07/25/2024 03:33 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

-This requirement is not met as evidenced by:
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Administrator will unlock all the residents room in memory care. In service training of all staff in memory care will sign off that they understand the regulation under resident personal rights.
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-Based on observation, the licensee did not comply with the section above for locking residents inside their room in memory care unit.
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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) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2