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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 08/23/2024
Date Signed: 08/23/2024 05:32:00 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
06/13/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230613112652
FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:MANDY TAYLORFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 62DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marissa Baldeomero, Memory Care DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are charging resident for services not rendered
INVESTIGATION FINDINGS:
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On 8/23/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Memory Care Director, Marissa Baldeomero.

During the investigation, LPA interviewed 3 residents and 3 staff. LPA obtained and reviewed documents (admission agreement, emergency information, care plan, physician's report, resident assessments, and resident detail ledger). Resident assessment dated 11/10/2022 indicated that resident (R1) was a level one (1) for care. However, R1's detail ledger revealed that R1 was charged for level three (3) care for dates after 11/10/2022.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 3
Control Number 15-AS-20230613112652
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: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87468.2(a)
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Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following...
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Facility has agreed to update R1 detail ledger and refund R1 for the difference according to the updated detail ledger if necessary. Facility will submit the updated ledger to CCLD by POC date.
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This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R1 for services not rendered which poses a potential personal rights violation to the 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
06/13/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230613112652

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:MANDY TAYLORFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 62DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Marissa Baldeomero, Memory Care DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not provide resident with a copy of an admissions agreement
INVESTIGATION FINDINGS:
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On 8/23/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegation above. LPA met with Memory Care Director, Marissa Baldeomero.

During the investigation, LPA interviewed 3 residents and 3 staff. LPA obtained and reviewed documents (admission agreement, emergency information, care plan, physician's report, resident assessments, and resident detail ledger). Interview with resident (R1) revealed that R1 had a copy of admission agreement, but did not know where it was placed.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3