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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 05/26/2022
Date Signed: 05/26/2022 01:44:10 PM


Document Has Been Signed on 05/26/2022 01:44 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: 74DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Bernadette Bender, Memory Care DirectorTIME COMPLETED:
01:50 PM
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On 05/26/2022, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit regarding self-reporting an AWOL incident in the memory care unit. LPA met with Bernadette Bender Memory Care Director and explained to the purpose of the visit.

The Director stated that 4 staff worked on the same PM shift on 5/23/22. The subject resident (R1) was noticed missing in the memory care at around 4:45pm, none of the staff heard the door alarm when R1 eloped, and how R1 eloped was unknown, 911 call was made. The Director confirmed that R1 was able to exit the facility and was found on the street after 2 hours of missing, R1 didn't return to facility after being found. Discharge paperwork was completed by her daughter the next day which was 5/24/22.

LPA inspected the memory care unit, there are 5 exit doors around and were observed to be locked during visit. LPA obtained and reviewed R1's physician's report, needs and services plan, admission orders, and staff schedule.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted with the Memory Care Director. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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Document Has Been Signed on 05/26/2022 01:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2022
Section Cited

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87705 Care of Persons with Dementia
(b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.

-This requirement is not met as evidenced by:
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Based on interviews and records review, the licensee did not comply with the section above for retaining R1 with dementia. R1 was able to AWOL which posed immediate safety risk to person 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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