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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:22:20 PM

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
08/07/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200807153407
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: 106DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anthony Garcia, Administrator/ED
TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident sustained multiple infected pressure injuries while in care
Staff fail to change resident's diaper frequently and when wet
Staff fail to reposition resident several times a day using proper technique
INVESTIGATION FINDINGS:
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On 04/26/22 at 12PM, 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: Resident sustained multiple infected pressure injuries while in care
Investigation Finding: SUBSTANTIATED
Based on interviews and records review, R1 was being treated for wound care by a home health nurse at the facility from 5/18/20 to 8/7/20. On 6/15/20 HHN observed that the wound was not healing as expected and by 7/11/20, HHN observed that a red wound was developing. On 8/5/20, HHN observed that R1’s wound was not healing due to contamination with urine. The facility staff were instructed to check for incontinence care need every hour; upon review of the care plan, there was no update made to the care plan with this direction. The preponderance of evidence has been met. Therefore, the allegation is substantiated.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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 5
Control Number 15-AS-20200807153407
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
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Allegation: Staff fail to change resident’s diaper frequently and when wet
Investigation Finding: SUBSTANTIATED
Based on interviews and records reviews, R1 was being treated for wound care by a home health nurse at the facility from 5/18/20 to 8/7/20. On 7/11/20, HHN observed a new red wound at the left buttock and on 7/24/20 instructed staff to change R1 promptly after each episode of incontinence to prevent deterioration of the wounds. On 8/5/20, HHN observed that R1s wound was not progressing due to continuing urine contamination. The preponderance of evidence has been met. Therefore, the allegation is substantiated.

Allegation: Staff fail to reposition resident several times a day using proper technique
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, HHN notified staff to reposition R1 every 2 hours while in bed and keep R1 clean and dry at all times for wound to heal on 06/24/20 and 07/06/20. On 06/26/2020 HHN brought in Occupational Therapist (OT) to train staff on proper resident repositioning techniques. On HHN’s routine wound care visit dated 07/11/20, a new wound on the left buttock which was observed to be red and reported this to staff. HHN again instructed staff to reposition R1 every 2 hours in bed and encourage R1 to hydrate and eat food. Upon review, it was found that this direction was not added to the care plan. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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 5
Control Number 15-AS-20200807153407
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
87468.2(a)(4)
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Personal Rights
(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper incontinence care and will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by resident sustaining pressure injuries while in care which posed a potential health & safety risk to resident in care
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Type B
05/26/2022
Section Cited
CCR
87464(f)(4)
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Basic Services
Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications…
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by staff failing to reposition resident in bed which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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 5
Control Number 15-AS-20200807153407
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
87411(c)(3)(B)
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Personnel requirements - General
All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following: (B) Importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control…
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining
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This requirement was not met as evidenced by staff failing to reposition resident which posed a potential health & safety risk to resident 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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: 4 of 5
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
08/07/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200807153407

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: 106DATE:
04/26/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Anthony Garcia, Interim ED
Cynthia Morris, Administrator/Executive Director		TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff fail to ensure wheelchair cushion and bed mattress are properly inflated
INVESTIGATION FINDINGS:
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On 04/26/22 at 12PM, 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: Staff fail to ensure wheelchair cushion and bed mattress are properly inflated
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was first admitted at the facility on 06/30/2017. LPA’s review of employee training summary dated 08/10/20 show staff training of 115.51 hours completed from 03/21/20 until 07/30/20 which included respecting resident’s rights (March & June 2020), safe lifting & transfer techniques (October 2019), service plans and special care needs. LPA’s review of resident assessments and narrative charting from 07/22/2017 until 08/26/2020 did not note anything about inflation of wheelchair cushion or bed mattress. LPA could not validate whether wheelchair cushion and bed mattress were properly inflated since staff is no longer available during that time for interviews. 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (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: 5 of 5