019200513-4-14-2022-15-AS-HHUL-CERRCW-20220525125500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/14/2022
Date Signed: 04/14/2022 12:03:45 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
10/07/2021 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20211007162353

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:	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:			TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Personal Rights - Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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On 04/14/22 at 11:50 a.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above allegation. LPA met with Anthony Garcia, Executive Director and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews with facility staff, residents, witnesses and complainant. Documents including but not limited to: R1’s Physician’s Report, home health records, Care Plan, discharge notes were obtained.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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-20211007162353

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: 04/14/2022

NARRATIVE

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On 4/30/2021, R1 was admitted to memory care unit from assisted living. An initial health assessment was completed on 5/26/2021 and no indication of any rashes during skin assessment. On 8/6/2021, S2 observed a wound on bottom of right foot, and notified R1’s responsible party and primary care physician. Wound care was initiated by Pine Park Health (PPH) and ProHealth Home Health (PHHH) on 8/19/2022 and 8/20/22; respectively. Staff were instructed to reposition R1 every 2 to 3 hours and offload pressure. Based on interviews with staff, staff reported that R1 was being repositioned as they were instructed. The Department was unable to provide or disprove there was neglect by the facility. Although, R1 sustained multiple wounds while at the facility, R1 was receiving wound care by PPH and PHHH. W1 stated home health was aware R1 sustained multiple pressure injury due to R1’s bed bound status and there were no concerns of staff being neglectful.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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