019200513-1-17-2023-15-AS-YFLS-CNG2U7-20230126164153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:57:20 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
01/11/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230111142713

FACILITY NAME:	PACIFICA SENIOR LIVING OAKLAND		FACILITY NUMBER:	019200513
ADMINISTRATOR:	GARCIA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	2330, 2350, 2361 E 29TH ST		TELEPHONE:	(510) 534-3637
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94606
CAPACITY:	197	CENSUS: 106	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Facility is not addressing issue with rodents in the kitchen
Staff does not ensure the kitchen is kept in clean, safe, sanitary conditions

INVESTIGATION FINDINGS:

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On 1/17/23 at 2:05 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to open a 10 day complaint visit or the above allegations. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit.

During the course of investigation, LPA interviewed Administrator, 3 staff (S1, S2 and S3) and the complainant (RP). LPA also reviewed work orders from the pest control company.

Adminstrator reported that the facility has a monthly contract with Orkin Pest control. Okin monitors for rodaent activity anbd sets traps throughout the kitchen outside areas.

***report continues on LIC9099C***

Unsubstantiated

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: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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-20230111142713

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: 01/17/2023

NARRATIVE

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**report continues from LIC9099***

S1 stated that she has not seen any rodents in the kitchen. S1 also stated that she is in the process of developing a cleaning schedule for the kitchen . Currently staff clean as they work.

S2 and S3 also stated that thetyhave not seen any rodents in the kitchen. S3 demonstrated to LPA how the floor drains in the kitchen are cleaned. All drains were observed to be clean at the time of the inspection.

This agency has investigated the above allegations. Based on records reviewed, and interviews 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 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: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

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