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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 11:43:56 AM

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-20220324151334
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:
08:50 AM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility doesn't have an Administrator.
Residents key fobs are in disrepair.
INVESTIGATION FINDINGS:
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On 8/30/2022 at 8:50 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 doesn't have an Administrator-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-20220324151334
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 - Residents key fobs are in disrepair-Substantiated

The Department has investigated this allegation and per records review and interviews, and found that disfunctional key fobs was an on-going issue and has not been repaired in timely manner. On 3/30/22, LPA toured the Salem Woods building with Administrator S3 to inspect the key fobs. LPA observed S3 tried to use FOB keys to open the doors which did not operate the door open.

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(s) 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-20220324151334

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:
08:50 AM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff did not ensure resident was taken to doctor's appointments.
Facility fire alarms are in disrepair.
Facility is not properly maintaining trash disposal.
INVESTIGATION FINDINGS:
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On 8/30/2022 at 8:50 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 - Staff did not ensure resident was taken to doctor's appointments-Unsubstantiated
The Department has investigated this allegation and per records review and interviews, and found that resident R2 was arranged to be transported from 2nd floor to 1st floor to a doctor’s appointment while the elevator was not working. R1 stated that R2 declined being transported because R2 was afraid of unsafe due to personal and health condition. R1 stated that staff also assisted R2 to change doctor’s appointment 2 weeks after.


Continue on LIC9099A-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-20220324151334
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 fire alarms are in disrepair- Unsubstantiated
The Department has investigated this allegation and per records review and interviews, and found that Annual Fire Inspection on Salam Woods Building was passed on 11/29/2021. No record for incident of fire alarm went off was found.

Allegation - Facility is not properly maintaining trash disposal-Unsubstantiated

The Department has investigated this allegation and per records review and interviews, and found that bulk pickup has been arranged by maintenance department and scheduled date was confirmed. On 3/30/22, LPA toured the areas where trash bins and dumpsters were, and observed that trash bins and dumpsters were empty, which were picked up on the trash date 3/29/2022 (every Tuesday and Thursday), A few items of chairs, tables and sofa were observed next to the dumpsters. Administrator S3 stated that management team was aware and has scheduled pulk pickup tomorrow. On 3/31/22, S3 provided a picture of showing the dumpsters area was clean to CCL.

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-20220324151334
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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Type B
09/06/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times....

This requirement is not met as evidenced by…

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Defeciency Cleared.

ED has awarded the contract of repairing key fobs system on 8/23/22, the project starting date is pending, and also, ED proactively keeps CCL updated.
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Based on record review, the licensee did not comply with the section cited above. LPA observed key fobs on Salam Woods Building did not operate to open the door 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