019200513-6-16-2022-15-AS-KHOS-CG2MJN-20220705093925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:19:59 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
07/27/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210727162312

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: 97	DATE:	06/16/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Yadira Valdiva, Business Manager		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not assisting resident with ADLs.

INVESTIGATION FINDINGS:

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

On 6/16/2022 at 10:45AM, Licensing Program Analyst (LPA), L. Hall and C. Fowler arrived unannounced to conduct a complaint investigation and deliver complaint findings for the allegation above. LPA met with Yadira Valdiva, Business Manager and explained the reason for the visit

During the course of the investigation LPA. G. Luk interviewed staff, Resident 1 (R1), and Witness 1 (W1). LPAs L. Hall and C. Fowler interviewed S3, S4, obtained the following documents: Admission agreement, advantage resident assessment, facility roster, invoice statement, outside agency/services documentation, physician's reports dated 2/9/2021 and 7/26/2021, hospice assessments, needs and services plan dated 2/10/2021, narrative charting, and resident assessment dated 2/10/21.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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 2

Control Number 15-AS-20210727162312

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: 06/16/2022

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

Continued from LIC9099.

Based on LPAs record review and interviews R1's condition had declined and R1 needed a higher level of care. R1 refused puree foods per hospice assessment and S4. Facility would finely chop food for R1, but R1 had little to no appetite. S1 stated that R1's family would speak to her personally regarding any changes relating to R1. R1 moved out of the facility on 8/3/2021 to a skilled nursing facility.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2