019200509-6-19-2026-15-AS-BFOG-DXQRGD-20260908130033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 06/19/2026
Date Signed: 06/19/2026 03:42:15 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
06/17/2026 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20260617160658

FACILITY NAME:	PACIFICA SENIOR LIVING UNION CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	LAGASCA-CRUZ, MARIE ANN		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 69	DATE:	06/19/2026
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Marissa Baldomero, Resident Services Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not ensure resident is accorded 3 meals per day at from the facility

Staff do not ensure call service lights are answered for residents care needs

INVESTIGATION FINDINGS:

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On 06/19/2026 at 11:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a 10-day complaint investigation and deliver findings for the allegations above. LPA met with Marissa Baldomero, Resident Services Director, and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with three (3) staff (S1, S2, and S3), eight (8) residents (R1, R2, R3, R4, R5, R6, R7, and R8), toured the kitchen and community store, obtained the personnel report (LIC500) and the facility roster. LPA also obtained the physician's report and assessment for R1.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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-20260617160658

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: 06/19/2026

NARRATIVE

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Continued from LIC9099.

Allegation: Staff do not ensure resident is accorded 3 meals per day at from the facility.

During the investigation the three (3) staff (S1, S2, and S3) all stated the residents are served three (3) meals a day. S1 stated there are snacks in the community store that is free and available to the residents at any time of the day. S2 stated during the shift two (2) meals are delivered to the residents that does not leave their rooms. S2 also stated if a resident that normally receives a meal in their room do not request a meal the med tech will find out why. S2 stated R1 gets up around 11:00am, and prefers for the caregivers to put the food on the counter in the room and R1 will warm it up when ready. S3 stated the residents receives three (3) meals. LPA toured kitchen and community store and observed more than a sufficient amount of food for the residents. All eight residents interviewed (R1, R2, R3, R4, R5, R6, R7, and R8) stated the facility provides three (3) meals a day. R2, R4, and R5, stated during interview that they purchase their own snacks for their rooms. R1 stated during interview she can press her call button to get food.

Allegation: Staff do not ensure call service lights are answered for residents care needs

S1 stated during interview that she has not received any complaints regarding the staff not answering the pendents. S1 stated the family of the residents or the resident themselves communicates with her. S2 stated during interview the caregivers are assigned to areas and if one is busy and a resident uses their pendent a backup staff is called to assist. S2 stated staff are given 15 minutes maximum to respond to a call, and so far that has not happened. S3

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20260617160658

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: 06/19/2026

NARRATIVE

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Continued from LIC9099C.

also stated if one staff is busy they will radio another staff to assist if a call is pending. R1 stated that LPA K. Nguyen addressed the service light issue. R1 also stated she feels there should be more staff to come right away, but when she press the pendent the caregiver comes. R2, R3, R4, R5, R6, R7, and R8 stated they have not had any issues when pressing the pendent and receiving a response. The caregivers come in a timely manner. R6 stated the caregivers come right away or if it is busy within 10 minuets.

Based upon observation and the interviews conducted during investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC9099 (FAS) - (06/04)

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