019200513-1-17-2023-15-AS-YFLS-CP2MKX-20230214084129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:01:36 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
06/29/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20220629154045

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: 106	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Questionable Death.
Facility administered medications to resident without physicians order.
Facility mismanaged medication resulting in overmedicating resident in care
Personal rights- resident spoken to inappropriate manner
Personal rights- facility staff handled resident in a rough manner
Responsible party not notified about resident's change in condition
Staff unable to communicate with residents due to language barrier
Lack of supervision- resident sustained several unwitnessed falls with injury.

INVESTIGATION FINDINGS:

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On 1/17/23 at 1:35 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, LPA interviewed S1 and S2, reviewed facility hospice roster for May and June 2022. LPA also reviewed R2’s records including physician's report, Medication Administration Records (MARs), needs and services plan, Physician Orders for Life-Sustaining Treatment (POLST), Death Report (LIC624A), SIR’s and Hospice nurse notes.

On July 13, 2022 LPA was able to speak with R2’s daughter(W1). W1 stated that R2 was admitted to the facility on 5/31/22 and died on 6/27/22, W1 was present in R2’s room when he passed.

***Report continues on LIC9099***

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)

Page: 1 of 3

Control Number 15-AS-20220629154045

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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Questionable Death. On 6/27/22 W1 decided to move R2 back to her home so she could monitor his care more closely. While moving R2 from his bed to a wheelchair he collapsed. The hospice nurse told S1 to call 911. S1 did so and then left R2’s room to retrieve his POLST from her office. When S1 returned to R2’s room the paramedics had pronounced R2 deceased.

Facility administered medications to resident without physicians order. Facility mismanaged medication resulting in overmedicating resident in care. S1 stated that all medications for R2 were handled by either W1 or the hospice nurse. LPA reviewed R2 medication orders on file and MARs from 5/31/2022-6/27/2022. No medications were administered by facility staff. All medications listed on the MARs were initialed by staff as “given to family to give later” and matched physician orders on file. W1 could not recall which medications were administered without the proper order nor which date said medications were taken by R2.

Personal rights- resident spoken to inappropriate manner. Personal rights- facility staff handled resident in a rough manner. Both S1 and S2 stated that they never saw any staff members at the facility speak to R2 in an inappropriate manner or handle R2 roughly.

Responsible party not notified about resident's change in condition. Both S1 and S2 stated that they were in constant contact W1 regarding her father’s condition. Both S1 and S2 showed LPA numerous text messages on their phones to and from W1.

Staff unable to communicate with residents due to language barrier. S2 stated that some of the housekeeping staff speak very little English but that they are not responsible for resident care. Care staff all speak English.

***Report continues on LIC9099C**

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)

Page: 2 of 3

Control Number 15-AS-20220629154045

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 LIC9099C***

Lack of supervision- resident sustained several unwitnessed falls with injury. LPA reviewed R2’s SIR’s and there was no documentation of any falls. S1 stated she never was told by staff that R2 had fallen.

This agency has investigated the above allegations. Based on records reviewed, and interview 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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