019200513-11-29-2022-15-AS-YFLS-CLUMFT-20221206083453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:09:54 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
07/05/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20220705092744

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: 104	DATE:	11/29/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Anthny Garcia, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff was not aware of resident DNR status

INVESTIGATION FINDINGS:

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

On 11/29/22.at 2:00 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegation. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit.

During the course of investigation LPA interviewed the complainant (RP) and S1.

RP’s interview confirmed that she was present in R1’s room when the facility nurse (S1) called paramedics for assistance with R1. RP further confirmed that S1 left R1’s room after calling the paramedics to go to her office to obtain R1’s POLST document.

***report continues 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: 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-20220705092744

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

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

***Report continue from LIC9099***

During S1’s interview she stated that R1 was admitted just weeks prior (5/31/22) as a hospice resident with a DNR in place. S1 was not in R1’s room when the paramedics allegedly performed CPR on R1. When S1 returned to R1’s room the paramedics had pronounced R1 deceased.

This agency has investigated the complaint alleging that facility staff was not aware of resident DNR status. 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 and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 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