019200513-4-29-2021-15-AS-KHOS-C2VKN7-20210510080241

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/29/2021
Date Signed: 04/29/2021 11:18:15 AM

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
12/10/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191210115917

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: 97	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ruth Ocon, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is in disrepair

INVESTIGATION FINDINGS:

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

On 4/29/2021 at 9:40AM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegation. LPA spoke with Administrator, Ruth Ocon. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed staff and complainant. LPA reviewed elevator repair documents. On 12/19/2019, LPA inspected/tested facility elevators and observed they were in operating condition. Elevator repair document revealed that the elevator was repaired by Paramount Elevator Corporation. On 10/30/2019, facility was given a citation due to a substantiated allegation for the complaint #15-AS-20191022160744 and given due date of 11/13/2019 to repair the community gate. However, on 12/19/2019, LPA observed that the front gate is still inoperable. S2 informed LPA that the entrance gate key pad does not work and won't stop for cars when they enter.

Based on information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D. Exit interview conducted. A copy of report and appeal rights will be emailed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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-20191210115917

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will submit receipt to show the community gate was repaired by POC date. If administrator is unable to repair the community gate by POC date, a plan will be submitted to CCLD
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not repairing the community gate which poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14	on how long it would take to repair the community gate to operable condition.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
12/10/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191210115917

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: 97	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Ruth Ocon, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide a safe environment for residents
Facility does not have a fire escape plan in place
Facility does not conduct fire drills

INVESTIGATION FINDINGS:

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

On 4/29/2021 at 9:40AM Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver complaint findings of the above allegations. LPA spoke with Administrator, Ruth Ocon. LPA explained due to the present shelter in place order by the Governor, delivering complaint findings is being done over video conference.

During the course of investigation, LPA interviewed staff and complainant. LPA obtained and reviewed fire drill documents, and fire escape plan.

Facility does not provide a safe environment for residents:
Interview with staff revealed that main facility door is automatically locked after 8PM and would require a key fob to open the door. Other exterior doors to the facility requires a key fob to open. After 8PM, visitors can ring the front door which will be transferred to on duty med tech who can open the door. On 12/19/2019, LPA inspected/tested all exterior doors and was locked after closing. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20191210115917

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: 04/29/2021

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

Facility does not have a fire escape plan in place:
LPA obtained and reviewed the facility's emergency disaster plan which included fire, earthquake, medical, and other various emergency situations. Interview with staff revealed that residents will stay in their room and staff will evacuate residents in their rooms.

Facility does not conduct fire drills:
On 12/19/2019, LPA obtained and reviewed fire drill documents which revealed that last fire drill was conducted on 9/26/2019.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4