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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:01:15 PM

Substantiated


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
12/01/2020 and conducted by Evaluator Lisha Holmes
COMPLAINT CONTROL NUMBER: 15-AS-20201201091707
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: 106DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Anthony Garcia, Executive Director.TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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On 01/19/23 at 12:20 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver complaint findings. A Facetime video conference was conducted by LPA D. Panlilio on 12/09/2020 in order to meet the initial 10-day complaint notification for the above allegation(s). LPA explained the purpose of the visit and met with Anthony Garcia, Executive Director.

During course of the investigation, the Department conducted interviews and record reviews. Three similar complaints was addressed. Complaint #15-AS-20200923100527 received 09/23/2020, #15-AS-20210416154529 received 04/16/21, and #15-AS-20210507092956 received 05/07/21. The noted complaints were received before and after the above allegations. The complaints were substantiated.

Allegation: Facility has pests
According to S2, vermin (roaches) were observed in the kitchen elevator and bathrooms. Records revealed that the facility had a documented history of pests over the course of 9 months. The facility was cited with a plan of correction.

Based on interviews conducted, records received, and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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 3
Control Number 15-AS-20201201091707
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
87555(b)(27)
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(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects... All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This requirement is not met as evidenced by:
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The facility covered part of the kitchen wall where the vermin/rodents had access to the facility, sticky traps for rodents were set up and checked weekly. Previous LPA requested a permanent plan on how to prevent rodents/vermin entering the facility. POC was cleared on 04/07/2021
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Licensee failed to keep the facility clean and free of pests which posed a potential health and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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
12/01/2020 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201201091707

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: 106DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident(s) in care
Resident's diapering needs are not being met
Staff are providing medication to residents without a prescription
Facility has inadequate diapering supplies
Facility is not providing adequate food service
Facility has inadequate toiletry supplies
INVESTIGATION FINDINGS:
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The above allegations refer to R1 and R2. R1 has been a resident since 07/01/2018. R1 has the capacity for self-care, bathing, dressing, grooming and toileting. R1’s last physician’s report does not note any history of skin conditions or breakdown. W1 did not have any knowledge of the allegations and subscribes to be informed when incidents happen at the facility. R1’s MAR appeared to be up to date at that time, photos of the monthly menu and the actual meals reveled that a variety and balanced diet was in place. Invoices also revealed that a surplus of toileting items were purchased and available. Records and interviews revealed that there was not a resident listed by the name of R2.

Based on interviews conducted, records received, and observations, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Anthony Garcia, Executive Director.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3