019200509-7-31-2024-15-AS-KHOS-D9FL3A-20240925082336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 07/31/2024
Date Signed: 07/31/2024 01:17:55 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
07/26/2024 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20240726132539

FACILITY NAME:	PACIFICA SENIOR LIVING UNION CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	ROBY, ROBERT B		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 60	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jeralyn May, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Sexual abuse

INVESTIGATION FINDINGS:

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On 7/31/2023 at 9:00am, Licensing Program Analyst (LPA), K. Nguyen arrived unannounced to conduct investigation for the above allegation. LPA met with Jeralyn May, Interim Administrator (AD), and explained the reason for the visit.

Allegation: Sexual Abuse- Unsubstantiated

During the investigation LPA interviewed staffs, Resident (R1), and collected/reviewed records. LPA collected the following for Resident (R1): Physician report, MAR, need and services plan, and facility charting log.

Report continued on LIC 9099c...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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-20240726132539

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: 07/31/2024

NARRATIVE

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LPA interviewed R1, R1 stated R1 does not recall the time frame of the event. R1 stated that nothing happened to R1. LPA interviewed S1, S2, S3, S4, S5, and S6 all indicated that they noticed that R1 memory have be declining alot and is on a lot of medication that might cause R1 to hallucinate. S6 stated that the polices officer spoke to S6 whom was investigating this incident indicated that he believes/ observed that R1 is hallucinating, because R1 is telling two different stories, and R1 doesn’t remembered.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC9099 (FAS) - (06/04)

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