019200513-10-13-2022-15-AS-YFLS-CKAT6U-20221017142743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:41:09 PM

Unfounded

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
10/05/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20221005120903

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:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:			TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Financial abuse
Facility would not allow resident to have phone calls from immediate family
Facility would not communicate with resident's POA

INVESTIGATION FINDINGS:

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On 10/13/22 at 2:15 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegations above. LPA met with Administrator, Anthony Garcia and informed him the reason for the visit.

During the course of investigation, LPA interviewed staff, reviewed R1's records including facility file, Power of Attorney document dated 9/04/21, Residence and Care Agreement and Resident Ledger.

LPA found the resident's ledger to be in order with checks documented and marked as payment to the facility.

The POA during R1's time at the facility was R1's sister as documented on the Power of Attorney document dated 9/4/21. The facility communicated with the POA as needed throughout R1's time at the facility. *** report continues on LIC9099C***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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-20221005120903

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: 10/13/2022

NARRATIVE

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***report continues from LIC9099***

During the review of R1's POA agreement it is stated "Care and Control of Person. My agent is authorized, in my Agent's sole and absolute discretion from time to time and at any time, with respect to the control and management of my person." In order to met this directive the POA instructed the facility to block all communication with R1's family in New Jersey. The POA stated that talking to his family in New Jersey upsets R1 and she didn't want that for R1.

This agency has investigated the complaint alleging financial abuse, facility would not allow resident to have phone calls from immediate family and facility would not communicate with resident's POA. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted, a copy of this reported provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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