019200513-11-18-2020-15-AS-KHOS-BVHLG6-20201119074412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 11/18/2020
Date Signed: 11/18/2020 06:18:13 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
07/28/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200728101332

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: 109	DATE:	11/18/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Amanda North, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not provide a healthful environment for resident.

INVESTIGATION FINDINGS:

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

On Wednesday, November 18, 2020, Licensing Program Analyst (LPA) C. Phomphachanh called facility to deliver findings to the above allegation. LPA conducted tele-visit via facetime with Executive Director, Amanda North. Due to the Executive Order for Shelter in Place set forth by the Governor, LPA was not able to deliver findings in person.

During the course of investigation, LPA conducted tele-visit, interviews, and reviewed pertinent documents.

For the allegation, facility does not provide a healthful environment for resident. Reporting Party (RP) stated that during a visit on Monday, July 27, 2020 morning at 11 AM, facility trash in the bathroom was full of soiled diapers adn waste, but clean before RP left the facility.

Continuation on LIC 9099 C - Page 1 of 2 Complaint Investigation Report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

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-20200728101332

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: 11/18/2020

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

Continuation - Page 2 of 2 Complaint Investigation

When LPA interviewed ED, ED stated that RP had sent photo to ED and ED instructed staff to throw the trash away immediately. ED stated that trash was from care staff cleaning up a resident's room. Majority of memory care residents do not have their own bathrooms, it is shared. The care staff throws the solid disposable linens in the trash, then housekeeper comes and pick up the trash during the day to be dispose. However, during the evening and graveyard shift, care staff is responsible to take the trash out.

When LPA interviewed S1, S1 stated that S1 is the housekeeper and does take out the trash in the bathroom twice before end of shift. S1 stated that there are 17 shared bathrooms and S1 is responsible for all housekeeping duties during the day, S1 will have to take multiple trips to the large trash bin at times. S1 did mentioned that care staff throws the soil items in the trash bins in the bathroom and S1 will go around and pick it up for disposal.

When LPA reviewed documents, morning schedule is covered for housekeeping duties and evenings/graveyard will be the care staff schedule to do parts of the housekeeping. LPA reviewed log, per shift has 3 signatures to check on the restrooms. When LPA conducted unannounced tele-visit, LPA did not observe an full trash bins.

Based on the interviews conducted, tele-visit for observation, and records reviewed, LPA found the allegation to be unsubstantiated. 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.

Exit interview conducted with Executive Director, Amanda North. Copy of report given via PDF email.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2