019200513-7-15-2020-15-AS-JMOS-BRMTSZ-20200718145958

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 07/15/2020
Date Signed: 07/15/2020 02:22:05 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
11/04/2019 and conducted by Evaluator Alicia Delmundo

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191104164112

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:	07/15/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:			TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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-Lack of supervision: resident (R1) sustained injury while in care.

-Facility failed to seek timely medical attention for resident (R1).

INVESTIGATION FINDINGS:

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On this day, July 15, 2020, Licensing Program Analyst (LPA) Delmundo conducted a tele-visit via FaceTime with Executive Director Amanda North to deliver the findings on the above allegations. LPA explained the reason for the tele-visit and discussed with Ms. North the deliverance of this complaint. Due to the Shelter in Place Executive Order by the Governor effective March 17, 2020 and management directive to telework, LPA was unable to deliver the findings in person.

During the course of investigation, the Department obtained copies of the following documents: Admission Agreements; LIC601 Identification and Emergency Information; Physician's Reports; Appraisals/Assessments; Hospital After Visit Summary; Incident Reports; medical records; Narrative Charting logs; staff and resident rosters. Staff (S1 and S2), Memory Care Director Fred Harmon, resident (R1) and R1’s family member (FM) were interviewed.

.......continued next page

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

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-20191104164112

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: 07/15/2020

NARRATIVE

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On October 31, 2019, resident (R1) was admitted to the facility. When R1’s sister left, R1 felt anxious and was “exit seeking”. R1 ran to the delayed egress door, kicked the door and sustained injury in the leg. Fred Harmon indicated he saw the ‘small cut’ injury of about 2 inches and at that time did not believe R1 needed to be sent to the hospital. He cleaned the wound, covered with bandaging and dressing and personally assigned himself to look after R1 until NOC shift staff arrived. He notified R1’s doctor of the injury at first he said through fax then later said through phone call, but medical records showed no call nor fax was made. NOC shift staff (S1) took over the care and checked R1 four times (4) times during her shift consistent with the Assessment and Narrative Charting log/notes. S1 noted that the bandaging needed to be changed early in the morning of November 1, 2019; however, R1 was combative. S1 informed the morning (AM shift) staff (S2) who attempted to change the dressing but felt the wrapping was inappropriate because the skin tear was bleeding. S2 informed Mr. Harmon and R1 was sent out to the hospital where it was noted that the laceration was a U-shaped about thirty (30) centimeters in length and three (3) millimeters in depth. Mr. Harmon stated R1’s skin is sensitive and believes that somewhere between NOC and AM shifts, R1 may have pulled on the bandage and ripped the skin even more. R1 was interviewed but was unable to provide information how he sustained the injury. FM indicated she was notified immediately after the incident occurred.

Based on all the information gathered, the allegations of resident (R1) sustained injury while in care and facility failed to seek timely medical attention for R1 are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided via e-mail.

SUPERVISOR'S NAME: Isaac Taggart	TELEPHONE: (510) 363-5912
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2020

LIC9099 (FAS) - (06/04)

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