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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:15:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
03/24/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220324123422
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: 104DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff member lacked qualifications.
INVESTIGATION FINDINGS:
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On 8/30/2022 at 11:45 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA explained the purpose of the visit with Executive Director (ED).

Allegation: Facility staff member lacked qualifications - Substantiated
The Department has investigated this allegation and per records review and interviews, and found that former administrator (S1) certificate was expired on 6/30/2021 but was approved for extension to 12/31/2021. S1 admitted that her Administrator certificate was not renewed. New Administrator S3 was assigned and performed Administrator responsibilities effective on 3/1/2022, No record of an active certified Administrator associated with facility was found in January and February in 2022.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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-20220324123422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING OAKLAND
FACILITY NUMBER: 019200513
VISIT DATE: 08/30/2022
NARRATIVE
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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 was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs 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 with ED. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
03/24/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220324123422

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: 104DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff are not adequately supervising residents
Facility is in disrepair (broken refrigerators)
INVESTIGATION FINDINGS:
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On 8/30/2022 at 11:45 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA explained the purpose of the visit with Executive Director (ED).

Allegation: Facility staff are not adequately supervising residents – Unsubstantiated
The Department has investigated this allegation and per interviews and records review found that no elopement incident during the subjected time period was found or remembered by staff member. Assisted living residents with dementia were observed wearing wander guard wrist band that will alert staff member when residents leave the building. After reviewing staff schedule, adequate staffing was observed.


Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20220324123422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING OAKLAND
FACILITY NUMBER: 019200513
VISIT DATE: 08/30/2022
NARRATIVE
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Allegation: Facility is in disrepair (broken refrigerators) – Unsubstantiated
The Department has investigated this allegation and per interviews and observation found that 1 broken freezer and 2 broken small refrigerators in the main kitchen did not affect facility operation. 1 big freezer and 2 big refrigerators located in lower level of the kitchen were observed well functional and have amble space to store food. Per reviewing the equipment order form, it's in the process of replacing broken equipment. Kitchen director S2 stated the broken freezer and refrigerators were used for keeping daily meals supplies such as prepared salad and ice cream for the day, and it would be efficient and convenience to have them repair or replace in the main level of kitchen instead of having staff walk back and forth.

Based on observation, records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with ED and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220324123422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PACIFICA SENIOR LIVING OAKLAND
FACILITY NUMBER: 019200513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by…
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Executive Director agreed to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.
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Based on record review, the licensee did not comply with the section cited above. LPA observed facility does not have an active certified Administrator associated in the month of January and February 2022 which poses a potential health and safety concern to persons 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: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5