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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 03/25/2021
Date Signed: 03/25/2021 03:13:53 PM

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 OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:AMANDA M DOMINGUEZ NORTHFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:197CENSUS: 100DATE:
03/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Ruth OconTIME COMPLETED:
03:15 PM
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On 03/25/2021, Licensing Program Analyst (LPA) Allison O'Hollaren (AO) conducted a case management meeting via telephone due to Shelter in Place order directed by the Governor. LPA spoke with Administrator Ruth Ocon.

While reviewing records for another matter, it was determined that Resident (R7) had a change of condition and R7's pre-admission appraisal was not updated. Staff (S10) stated the type of care S10 provides to address R7's needs. Administrator Ruth Ocon agrees to update pre-admission appraisal for R7.

In addition it was determined that two staff (S9 and S11) that are confirmed by Staff (S3) to be currently working at the facility have associations that have ended. Staff (S3) confirmed both staff did not have a break in employment and was not aware of how staff became disassociated to the facility. Administrator Ruth Ocon agrees to associate both staff in Guardian or submit a LIC 9182 to CCL.

Another staff (S13) is currently inactive, but is confirmed by S3 to be working at the facility and did not have a break in employment. S13 received background clearance in 2005 when facility was under a different license and S3 was unaware that the background clearance did not transfer. Administrator Ruth Ocon agrees S13 will no longer work at the facility until S13 receives background clearance.

LPA AO determined to issue technical violations.

Exit interview conducted with administrator and a copy of this report was provided by email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021
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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