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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 10/01/2024
Date Signed: 10/01/2024 01:56:15 PM


Document Has Been Signed on 10/01/2024 01:56 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: 56DATE:
10/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Marissa Baldomero, Resident Services Director TIME COMPLETED:
02:10 PM
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On this day at around 1:10 pm, Licensing Program Analyst (LPA) K. Nguyen conducted a case management visit in connection with an incident reported by the facility. LPA met with Resident Services Director, Marissa Baldomero and Operation Specialist, Kathy Valencia and explained the purpose of the visit.

LPA received an UIR dated on 9/17/24 regarding an elopement. LPA interviewed S1 stated on the day of the incident staff walked R1 on a daily routine to visit R1 wife (lunch and dinner). R1 decided to take a walk and R1 wife cannot stop R1 from taking a walked. After R1 took off the wife called the front desk and informed us that R1 had taken a walk. S1 stated that this is a new behavior for R1 to walked off from R1 wife apartment. S2 stated that it was an agreement between the family and the facility to have R1 visit his wife on a daily routine. After R1 wife informed us we immediately send out staff to search for R1 and found R1 near senior center. S2 stated that the care plan has been update to R1 wife go to visit R1 in memory care. S1 stated that R1 wife stay in Assisted Living so when R1 took off there was no alarm that went off, due to assisted living unit. S2 is keeping a close communication with R1 family members.

No deficiency was noted during the visit.

A copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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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