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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 03/24/2021
Date Signed: 06/02/2021 02:02:49 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
02/19/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210219160021
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:
03/24/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Ruth OconTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is in disrepair
Facility is not meeting menu requirements
Administrator failed to work effectively with social agencies
Facility has bed bugs
INVESTIGATION FINDINGS:
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THIS IS AN AMENDMENT OF LIC9099 COMPLAINT INVESTIGATION REPORT DATED 3/24/2021.

On 03/24/2021 at approximately 10:05am Licensing Program Analysts Allison O'Hollaren and Lizette Francisco conducted an unannounced complaint visit meeting with Administrator, Ruth Ocon. Due to State's current shelter in place order pertaining to COVID-19 it was not possible to perform this visit at the facility. The visit was performed by telephone. The purpose of the call is to deliver finding on the above allegations.

During the course of the investigation, LPAs toured facility, collected documents, obtained information, and interviewed 8 residents and 7 staff.

Continued LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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-20210219160021
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: 03/24/2021
NARRATIVE
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Allegation: Facility is in disrepair
Based on LPAs’ observation, facility is in disrepair. LPAs observed sink in medication room had no p-trap, so water was being drained into a bucket underneath the sink.

Allegation: Facility is not meeting menu requirements


Based on interviews with staff and record review facility is not meeting menu requirements. Facility was unable to provide facility menu of seven days in advance, nor copies of the menu for last thirty days.

Allegation: Administrator failed to work effectively with social agencies
Based on interviews with two reporting parties, administrator failed to work effectively with social agencies. Two agencies informed LPAs that administrator failed to respond to emails and voicemails including regarding addressing pests in the facility, and COVID-19 infection prevention protocols and COVID-19 status in the facility, and did not follow agencies’ recommendations.

Allegation: Facility has bed bugs
After interviews with a reporting party, Staff (S2), and Resident (R9) it was determined that the facility has bed bugs in Resident's (R10's) bedroom.

Based on LPAs’ observation, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and Appeal Rights provided. Due to the State's current Shelter in Place Order, a copy of this report was provided by email.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210219160021
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: 03/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2021
Section Cited
CCR
87405(h)(8)
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87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (8) work effectively with social agencies. This requirement was not met as evidenced by: Based on
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By POC date administrator agrees to review regulation and implement a protocol and submit a copy to CCLD.
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interviews conducted two agencies stated that administrator is not communicating effectively with agencies which poses a potential health and safety risk to residents in care.
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Type B
04/07/2021
Section Cited
CCR
87307(d)(2)
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87307 (d) The following space and safety provisions shall apply...: (2) The premises shall be maintained in a state of good repair... This requirement was not met as evidenced by: LPAs observed sink in medication room
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Administrator agrees to send a video and photo of the repaired pipe to CCL by POC date.
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had no p-trap, so water was being drained into a bucket underneath the sink.
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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210219160021
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: 03/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2021
Section Cited
CCR
87303(a)
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87303 (a) The facility shall be clean, safe, sanitary... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement
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By POC date, administrator agrees to send CCL an invoice from Ecolab, bed bugs maintenance logs from 03/24/2020-03/24/2021, and a copy of bed bug protocol recommendations from agency.
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was not met as evidenced by: Based on staff, resident, and reporting party interviews, facility failed to prevent bed bugs in R10's bedroom which poses a potential personal rights of residents in care.
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Facility will also give every resident and responsible party a flyer on reporting information for bed bugs and submit a copy of the flyer to CCLD and a copy of self-certification letter to be sent to CCLD by POC date.
Type B
03/31/2021
Section Cited
CCR
87555(b)(6)
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87555 (b) The following food service requirements shall apply:
(6) ...menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days… Based on
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Administrator agrees to review regulation and conduct training of kitchen staff. Administrator will submit a copy of training agenda with staff signatures to CCL no later than POC date.
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record review, Facility was unable to produce LPAs a facility menu of one week nor copies of the menu in the last thirty days which poses a potential personal rights of residents 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4