019200513-6-4-2020-15-AS-JMOS-BQH2A4-20200611171254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 06/04/2020
Date Signed: 06/04/2020 03:35:58 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
01/06/2020 and conducted by Evaluator Celia Phomphachanh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200106111844

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: 124	DATE:	06/04/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amanda North, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Residents are not provided privacy while in care.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On Thursday, June 4, 2020 at 10:30 AM, Licensing Program Analyst (LPA), C. Phomphachanh conducted an announced tele-visit via Facetime with Administrator, Amanda North for deliverance of these allegations. LPA explained to the Administrator that due to the Shelter in Place Executive Order set forth by the Governor until further notice, LPA is unable to deliver the findings in person.

During the course of the investigation, LPA conducted interviews and reviewed documents relating to the allegations. LPA discovered the following:

For the allegation: Residents are not provided privacy while in care. Reporting party (RP) stated that during the process of the facility remodeling residents' shared bathrooms in Memory Care Unit, RP observed a hole in the wall above the toilet.

Continuation on LIC 9099 C, Complaint Investigation Report Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

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 2

Control Number 15-AS-20200106111844

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: 06/04/2020

NARRATIVE

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Continuation LIC 9099 C, Complaint Investigation Report Page 2 of 2

When LPA interviewed Administrator, Administrator stated the bathrooms at the Memory Care were being remodeled to remove toilet seat cover dispenser, then covered with sheet rock to fulfill the hole in the wall. Administrator stated residents were informed of the remodeling and directed to a bathroom residents should use during this process. Administrator mentioned that there are black plastic covering the hole in the wall until Contractors comes out to fix the hole.

When LPA visited the facility, the wall was covered with black plastic during the remodeling process. Some of the bathrooms were inaccessible and secure with plastic to prevent residents from using them. Therefore, facility did not alter the size or add any additional space to require a permit. The facility was removing the seat protector dispenser that was imbedded on the wall and replacing the open hole with sheet rock before painting the wall. This remodeling process was completed on January 28, 2020. This allegation is UNSUBSTANTIATED.

For the allegation: Facility is in disrepair. When LPA interviewed RP, RP stated that facility is old and falling apart. When LPA interviewed Administrator, Administrator stated that the facility is a very old building. Facility has housekeepers that clean the public areas hourly and maintenance person on duty daily. The facility is over 100 years old and building structure is in tact. LPA observed facility, facility is habitable. Facility does provide maintenance services to address any issue on a as needed basis. This allegation is UNSUBSTANTIATED.

Based upon the information obtained during investigation by LPA, the above allegations are UNSUBSTANTIATED . A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020

LIC9099 (FAS) - (06/04)

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