019200513-4-26-2022-15-AS-KHOS-CE4P5W-20220504110124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:35:55 AM

Substantiated

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
01/07/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220107152901

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:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anthony Garcia, Administrator/Executive Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide a safe environment for resident

INVESTIGATION FINDINGS:

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

On 04/26/22 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Facility does not provide a safe environment for residents
Investigation Finding: SUBSTANTIATED
Based on interviews and observations, facility does not provide a safe environment for residents. On 1/06/22 at 2:50PM, LPA toured the Salem Woods building with administrator (ADM) to inspect the exterior doors. LPA observed both exterior doors were not opening automatically. LPA observed ADM tried to use FOB keys to open the doors which did not work along with broken handicap plates that do not open the doors from the inside automatically located on the other side of the building.
Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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-20220107152901

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: 04/26/2022

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

ADM stated she has been working with 2 specialty door companies since March 2021 with exterior doors still not functioning properly. On 03/16/22, another LPA observed the FOB key and button to activate the elevator in the garage did not work. LPA interviewed 2 residents at Salem Woods who stated they were not able to use the elevator from the garage to the upper levels in the last several months.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20220107152901

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: 04/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/26/2022 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	Personal Accommodations & Services: The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD proof of repairs to permanently fix broken building elevator, exterior doors & FOB keys for residents in care.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by non functioning building elevator, exterior doors & FOB keys which posed a potential Health & Safety risk to residents in care	8 9 10 11 12 13 14
	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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 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
01/07/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220107152901

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:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anthony Garcia, Administrator/Executive Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not allowing residents to have visitors

INVESTIGATION FINDINGS:

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

On 04/26/22 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Based on interviews and record reviews, resident’s (R1) authorized representative stated on 01/12/22 that they have no issues with the COVID restrictions at the facility. LPA reviewed a copy of the COVID email dated 01/07/22 sent by the administrator to all residents and authorized representatives regarding facility’s COVID policies on indoor and outdoor visits. Indoor visits required visitors to be fully vaccinated and boosted and must be tested prior to the visit. The test can be done with a rapid antigen test one day prior to the visit or a PCR test 2 days prior to the visit. Outdoor visitors do not need to have vaccination or booster requirements but need to be tested prior to the visit. 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. Exit Interview conducted and a copy of this report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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

LIC9099 (FAS) - (06/04)

Page: 4 of 4