019200513-6-4-2020-15-AS-JMOS-BQEV5Z-20200609160847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 06/04/2020
Date Signed: 06/04/2020 12:49:08 PM

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
01/29/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200129150012

FACILITY NAME:	PACIFICA SENIOR LIVING OAKLAND		FACILITY NUMBER:	019200513
ADMINISTRATOR:	AMANDA M DOMINGUEZ NORTH		FACILITY TYPE:	740
ADDRESS:	2330, 2350, 2361 E 29TH ST		TELEPHONE:	(510) 534-3637
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	197	CENSUS: 124	DATE:	06/04/2020
		ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amanda North, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained a leg tear while in care.
Staff handled resident in a rough manner.
Facility did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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On Thursday, June 4, 2020 at 9:00 AM, Licensing Program Analyst (LPA), C. Phomphachanh conducted an announced tele-visit via Facetime with Administrator, Amanda North. LPA explained to the Administrator that due to the Shelter in Place Executive Order set forth by the Governor until further notice, LPA is unable to deliver the findings in person.

During the course of the investigation, LPA interviewed Reporting Party, Staff (S2, S3), and R1. LPA reviewed R1's medical file records, Emergency discharge records, Home Health notes, and other pertinent documents.

For the allegation: Resident sustained a leg tear while in care. LPA reviewed records; records indicated that R1 has reoccurring leg wound on right shin. R1 has very thin skin and it easily can tear when bandage is changed. Home Health Nurse has been coming to care for R1's leg wound since July 2019 until present. Therefore, this allegation is UNSUBSTANTIATED.

Continuation on LIC 9099 C, Page 1 of 2 Complaint Investigation Report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

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 2

Control Number 15-AS-20200129150012

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 OAKLAND	FACILITY NUMBER: 019200513
	VISIT DATE: 06/04/2020

NARRATIVE

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Page 2 of 2 Complaint Investigation Report

For the allegation: Staff handled resident in a rough manner. LPA interviewed S2, S2 declined being near R1 when incident occurred. S2 stated that S2 went to R1's room to do a check up for dinner and observed R1 has blood leaking on R1's right leg. S2 instantly went to get S3, who is a Med Tech to tend to R1's injury. When S3 was interviewed, S3 indicated S3 was only present when S2 went to get S3 for help. No other witnesses were present. When R1 was interviewed, R1 stated that when staff touch R1's leg, R1 is in pain. Therefore, there is no substantial evidence that staff handled resident in a rough manner. This allegation is UNSUBSTANTIATED.

For the allegation: Facility did not seek medical attention to resident. When records were reviewed for incident report, medical records, and Emergency discharge notes, LPA discovered when R1's wound becomes painful or worsens, R1 is immediately sent to the Emergency Room. This incident occurred on 1/12/2020, R1 went to Emergency Room same day. Therefore, this allegation is UNSUBSTANTIATED.

Based upon the information obtained during investigation, the above allegations are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted via tele-visit with Administrator, Amanda North. Copy of report via PDF file will be emailed to Administrator.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

LIC9099 (FAS) - (06/04)

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