019200513-2-15-2023-15-AS-KHOS-CPAVCX-20230222151951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 02/15/2023
Date Signed: 02/15/2023 03:20:16 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
01/30/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230130110824

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: 104	DATE:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff have not repaired a washing machine for the residents

INVESTIGATION FINDINGS:

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On 2/15/23 at 3:00 p.m., Licensing Program Analyst (LPA) G. 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 the facility's administrator (ADM). LPA toured the independent living side of the facility and observed 1 washing machine (GE manufacturer) with an out of order sign taped to it. ADM was not able to produce records of repairs attempts for the washing machine.

Based on LPA’s observations and interviews conducted 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) and are being cited on the attached LIC 9099D.

Exit interview conducted, a copy of this report and appeal rights provided.

Substantiated

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: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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-20230130110824

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: 02/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/15/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Administrator to do the following: Have the necessary repairs completed or replace the washer with an operational unit by the POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: based on interviews and inspection. the licensee did not comply with the section above. LPA observed a clothes washer in the Salem Building with an out or order sign on it which poses a potential safety risk to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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