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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 11/28/2023
Date Signed: 11/28/2023 05:32:56 PM

Substantiated


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
11/22/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20231122143232
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: 64DATE:
11/28/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Robert 'Rob' Roby/Executive Director and
Assited Living Director Shenina Robinson-Mason.		TIME COMPLETED:
05:40 PM
ALLEGATION(S):
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Facility staff did not ensure the resident file was up to date.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a 10-day complaint visit. LPA met with Executive Director (ED) Robert 'Rob' Roby and informed the reason for visit.

LPA obtained copies of resident roster, conducted interviews, and reviewed resident records.

It was alleged that when staff contacted 911 there were just blank pages in the emergency binder for residents so staff could not provide accurate information to the first responders.

LPA interviewed 2 staff (S1 and S2) who stated when 911 is called, the facility has emergency binder that contains document for the resident which is provided to the first responder. According to S2 the emergency binder contains residents' Face Sheets, information including doctor's order of medications, insurance, and resident's diagnosis.
....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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 4
Control Number 15-AS-20231122143232
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: 11/28/2023
NARRATIVE
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LPA selected 4 residents from the roster and reviewed their records. LPA observed 3 of the 4 residents do no have records on the emergency binder. The ED also checked the emergency binder and didn't see any documents for the 3 residents.

Based on information gathered, the preponderance of evidence is met, therefore. the allegation of facility staff did not ensure the resident file was up to date is closed as substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20231122143232
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87506(a)
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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Executive Director to check the emergency binder and have the documents completed for all residents, Self-certification to be submitted by 12/12/2023.
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-This requirement is not met as evidenced by:
-Based on records review and interviews, the licensee did not comply with the section above for not having records in the emergency binder for 3 out of 4 residents which pose potential health and personal rights risks to persons 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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4