019200513-6-4-2020-15-AS-JMOS-BQEV3D-20200609160430

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 06/04/2020
Date Signed: 06/04/2020 04:56:01 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
02/10/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200210143429

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:	10:00 AM
MET WITH:	Amanda North, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to safeguard resident's personal belongings.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On Thursday, June 4, 2020 at 10:30 AM, Licensing Program Analyst (LPA), C. Phomphachanh conducted an announced tele-visit via Facetime with Administrator, Amanda North for deliverance of these allegations. 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 conducted interviews and reviewed pertinent documents.

For the allegation: Facility staff failed to safeguard resident's personal belongings. Reporting party is referring to a black amplifier missing from the apartment. When LPA interview staff (S2 and S3), staff declined seeing the item. S2 stated that various family members and family friends came in different times and days to assist with moving items from the apartment. When LPA interviewed W1, W1 recalled W2 only taking the guitar.

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

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-20200210143429

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continuation LIC 9099 C, Complaint Investigation Page 2 of 2

When LPA interviewed W2, W2 indicated that W2 removed 2 guitars and 2 bass not a black amplifier. W2 provided a photo of where the black amplifier was located in the closet, LPA was not able to determine if it was an amplifier due to the coverings and other items in the closet.

When LPA reviewed R1's file, R1 did not list any valuable property in the records upon admission to the facility. When LPA reviewed Move Out Responsibility documentation, the facility is not responsible for any items left when moved out. This documents were signed by R1 and Administrator on 10/29/2019.

Based upon the information obtained during investigation, the above allegation is 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.

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)

Page: 2 of 2