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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 01:56:37 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
02/10/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210210121452
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 not adhering to COVID-19 infection control
Facility staff do not have required and appropriate training
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) 285-3928
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 8
Control Number 15-AS-20210210121452
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 not adhering to COVID-19 infection control
Based on LPAs’ observations and interviews with 2 reporting parties, the facility failed to
adhere to COVID-19 infection protocols. During the onsite initial 10-day complaint visit on 02/22/2021, facility was in COVID-19 outbreak status. The following observations were made: LPAs observed residents not socially distanced while waiting in line in first floor corridor, residents in memory care unit were not socially distanced during group activity, one staff wearing surgical mask pulled down below the mouth in reception area and within 6 feet of a resident, and communal dining and group activities were still being conducted despite local public health recommendation. In addition upon entry of the facility LPAs were not given symptom-check screening questionnaire when checking in at the front desk and LPAs observed pulse oximeter being used on multiple visitors without disinfecting pulse oximeter per use.

Allegation: Facility staff do not have required and appropriate training
Based on record review Med-tech Staff (S8) and (S12) did not complete eight hours of in-service training on medication-related issues in a 12-month period.

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) 285-3928
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 8
Control Number 15-AS-20210210121452
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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THE PAGE IS INTENTIONALLY LEFT BLANK DUE TO DOCUMENT BEING AMENDED.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Citations on this Visit Report are Under Appeal!

Control Number 15-AS-20210210121452
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)
Under Appeal
Type A
03/25/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful... accommodations...
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By POC date, facility will submit CCL a copy of HAI report and a copy of action plan to address recommendations.
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This requirement is not met as evidenced by: Based on LPA observation, facility did not follow COVID-19 infection prevention protocols which poses an immediate health and safety risk to residents in care.
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Type B
03/31/2021
Section Cited
HSC
1569.69(b)
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1569.69 (b) Each employee ...who continues to assist residents with the self-administration of medicines, shall also complete eight hours... training on medication-related issues each succeeding
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Administrator agrees to audit all staffs' training logs to ensure faciliy is in compliance with training requirements. A copy of self-certification letter to be sent to CCLD by POC date.
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12-month period. This requirement was not met as evidenced by: Based on record review Staff (S8) and (S12) did not have required training which poses a potential health and safety risk to 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 15-AS-20210210121452
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)
Deficiency Dismissed
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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Deficiency Dismissed
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 15-AS-20210210121452
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)
Deficiency Dismissed
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.
Deficiency Dismissed
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
02/10/2021 and conducted by Evaluator Allison O'Hollaren
COMPLAINT CONTROL NUMBER: 15-AS-20210210121452

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 failed to administer medication according to doctor's order
Facility failed to meet resident’s dietary needs
Biohazardous waste is not properly disposed
Facility failed to notify appropriate parties when resident had a change in condition
Facility staff is mishandling resident’s money
Uncleared staff working in the facility
INVESTIGATION FINDINGS:
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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.

Allegation: Facility staff is mishandling resident’s money
Based on interviews with 4 residents and 2 staff, 4 out of 4 residents and 2 of 2 staff revealed that facility does not handle or safeguard residents' money.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 15-AS-20210210121452
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 failed to administer medication according to doctor's order
Based on interviews with 4 residents, 4 out of 4 residents stated that their medications were administered to them according to the scheduled times.

Allegation: Facility failed to meet resident’s dietary needs
LPAs interviewed a sample of residents who are on a special diet, 2 of 2 residents stated facility is meeting their dietary needs. Staff (S9) said meals are prepared according to resident’s dietary needs indicated on the list. LPAs reviewed records and observed a list of residents with dietary restrictions.

Allegation: Biohazardous waste is not properly disposed
LPAs interviewed Staff (S8) who stated insulin syringes are disposed in sharp containers in residents' rooms. On 03/20/2021 LPA Allison O'Hollaren (AO) conducted a tele-visit with Staff (S2) and toured two residents' bedrooms. LPA AO observed sharp container with insulin syringes in both resident rooms.

Allegation: Uncleared staff working in the facility
LPAs collected staff roster and verified that all staff on staff roster have fingerprint clearance.

Allegation: Facility failed to notify appropriate parties when resident had a change in condition.
Based on progress notes in resident's file, facility did notify appropriate parties when resident had a change in condition.

Based on interviews conducted, tele-visit, observations, and records reviewed, LPAs found the above allegations to be unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted with Administrator. Copy of report provided via email.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8