019200513-4-27-2022-15-AS-KHOS-CE4PED-20220504111458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:32:11 PM

Unsubstantiated

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
04/26/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220426163958

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: 106	DATE:	04/27/2022
		UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Joann Nisperos, Resident Services Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is not following COVID-19 protocols

INVESTIGATION FINDINGS:

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On 04/27/22 at 2:41PM, Licensing Program Analysts (LPAs) D Panlilio and G Clark conducted an unannounced complaint investigation, met with Resident Services Director (RSD) who is the manager on duty for the day and delivered the investigation finding to RSD. LPAs explained the purpose of the visit with RSD.

During investigation, LPAs observed the front entrance had COVID signages in place and 4 staff wearing face masks while on duty. Routine symptom checks (temperature checks, COVID questionnaire) were done. LPAs observed hand sanitizers available as well as additional COVID signages posted in common areas as reminders to practice cough/sneeze etiquette, social distancing, wearing face masks, visitation policies. RSD stated that faciity staff continue to follow COVID protocols and have housekeeping conduct daily cleaning and disinfection of commonly touched surfaces.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220426163958

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: 04/27/2022

NARRATIVE

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RSD stated she tried to administer the COVID antigen tests yesterday to R1 & R2. However, R1 was out of the facility running errands and R2 told RSD that she already got tested 3 times earlier in the week and the test results were all negative. LPAs requested RSD to administer the antigen tests on R1 & R2 while at the facility. LPAs observed both antigen test results on R1 and R2 came back negative. During the visit, R1 & R2 confirmed with LPAs that RSD tried to administer the COVID antigen tests on 04/26/22.

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 allegation is UNSUBSTANTIATED.

No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC9099 (FAS) - (06/04)

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