019200513-2-2-2022-15-AS-BFOG-CNGSMP-20230127130013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 02/02/2022
Date Signed: 02/02/2022 04:56:45 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
01/26/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220126125900

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:	02/02/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Ruth Ocon/Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is not following COVID-19 protocols.

Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Ruth Ocon/Executive Directorand informed the purpose of visit.

LPA conducted inteviews.and obtained copies of resident roster and staff schedule/
.
Allegation:Facility is not followiing COVID-19 protocols
It was alleged that faclity is not protecting residents or staff from COVID in an acceptable manner. It was further alleged that resident (R1) who was tested positive was seen walking around without mask and talking to other residents on the day this resident was tested positive.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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-20220126125900

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: 02/02/2022

NARRATIVE

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Ruth Ocon stated R1 is an independent living (IL) resident who came to the dining room one time, She talked to R1 and since then R1 didn't come to the dining room. Staff (S1) indicated R1 is an IL resident and confirmed R1 no longer comes to the dining room. Review of resident roster confirmed R1 is an IL resident. LPA observed the front desk person screening essential visitors. LPA further observed visitors wearing masks and the staff whom LPA interviewed were wearing N95 mask. LPA also observed residents in the front lobby wearing mask and 6 feet away from each other. LPA interviewed S1 and maintenance director (S2) who both indicated they don full PPEs before entering the apartments of residents positive of COVID and doff off when leaving the apartments.

Allegation: Facility is in disrepair.
It was alleged that the front gate does not close due to electrical issue. When LPA arrived, LPA observed the front gate closed. LPA has to use the dial pad to speak to the front desk person who opened the gate. Ruth Ocon stated the front gate was not operational about a week or 2 weeks ago because of power outage and the front gate was open. Interview of maintenance staff (S2 and S3) confirmed the gate was open for 1 day and they observed PG&E personnel working about 2 blocks away from the facility. S2 said that he and S3 checked and that upon checking his (S2) determination was that there was loss of power. They turned on the gate and it rebooted and the gate came back up and operational.

Based on observation and interviews, there's is not enough preponderance of evidence that violations occurred, therefore the allegations are closed as unsubstantiated.

No deficiencies cited.

Exit interview conducted and copy of this report provided to Ruth Ocon.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC9099 (FAS) - (06/04)

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