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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:55:31 PM


Document Has Been Signed on 04/28/2022 12:55 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:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Bernadette Bender, Memory Care DirectorTIME COMPLETED:
01:20 PM
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On 04/28/2022, Licensing Program Analyst (LPA) C. Fowler conducted a case management and met with Bernadette Bender Memory Care Director. LPA explained to Bernadette purpose of the visit.

During the course of investigation for different issues, a concern regarding Resident 2 (R2) not getting assistance with brushing teeth was addressed. LPA L. Fontanilla reviewed R2’s Physician’s Report dated 3/26/2019 and Appraisal Needs and Services Plan (ANS). Documents reviewed indicate R2 is independent with ADLs and is capable for self-care. On 2/5/2021, R2’s ANS was updated and added partial assist with hygiene/oral care, evacuation, elopement and confusion and reminders for activities.

On 3/24/2022, LPA L. Fontanilla interviewed 4 caregivers who have been working at the facility for 2-7 years and have worked with R2. All caregivers interviewed state that R2 is ambulatory and independent with ADLs. Staff told LPA that R2 needed cueing or reminders only with ADLs such as brushing teeth and changing clothes. Staff would hand R2 toothbrush/toothbrush but would not allow staff to brush R2’s teeth.

There is no deficiency noted for this visit.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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