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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:57:34 PM

Unsubstantiated


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
05/26/2021 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20210526120635
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:
11/29/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Anthony Garcia, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has bed bugs.
Resident did not receive showers as agreed to.
Staff stored another resident's belongings in a resident's room.
Bathroom showers are dirty.
Staff do not wear gloves when caring for residents.
Resident pendant was not answered by staff.
Staff did not assist the resident with incontinence.
INVESTIGATION FINDINGS:
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On 11/29/22.at 1:30 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit.

During the course of investigation, LPAs A. O’Hollaren and L. Francisco interviewed the complainant (RP) and 5 staff. LPAs obtained bed bug treatment logs, shower skin check assessment documents, end of shift reporting documents, med tech communication logs and toured the facility.

Based on documents received the facility had a proactive treatment plan for bed bugs in place and was activity treating rooms identified as having bed bugs.

**report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 2
Control Number 15-AS-20210526120635
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: 11/29/2022
NARRATIVE
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***Report continues from LIC9099***

Skin check shower logs documented that the RP was receiving showers regularly, on occasion the RP would refuse showers.

The Executive Director (ED) reported that some resident’s belongings had to be temporarily moved to accommodate the bed bug treatment activities.

During the LPAs tour of the facility it was observed that the shower rooms were clean with the exception of one room that had a faint smell of urine. Staff were observed to be wearing gloves.

S3 reported that staff have 15 minutes to answer pendent calls in their assigned area. If staff cannot answer the pendent, they radio in for assistance. Facility keeps a pendent log to see who cleared the pendent and when.

End of shift reporting documents chart that RP received incontinence care on a regular basis.



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, a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2