<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 02/24/2023
Date Signed: 02/24/2023 06:00:19 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
03/17/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210317082415
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: 90DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Anthony Garcia/Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not respond to resident's call in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit.

During the course of investigation, the Department obtained copies of resident roster, staff schedule and call button/pendant records. Interviews were conducted and call button/pendant records were reviewed.

On 3/25/21, LPA interviewed family member (FM1) who stated they (family) visited resident (R1) on 3/22/21, and they pressed the call button for assistance, staff only came after 25 to 30 minutes. LPA was not able to obtain information from R1. On 12/01/21, LPA interviewed R2 and R3. R2 stated when she pressed her pendant staff responds within 10 to 15 minutes while R3 said staff responds at most 30 minutes. Review of call button records for the said incidents showed several response times ranging from 16 minutes 57 seconds to 65 minutes to 59 seconds.
.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
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 7
Control Number 15-AS-20210317082415
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: 02/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on records review and interviews, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Anthony Garcia.

Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
03/17/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210317082415

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: 90DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Anthony Garcia/Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff left resident on the floor for extended period of time.

- Staff do not follow the admission agreement in accordance with the service plan.

- Resident's room does not have adequate heater.

- Staff denied resident the right to reasonable visitations.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to conitnue the investigation of the above allegations, and close the complaint. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit.

During the course of investigation, the Department obtained copies of resident rosters and staff schedule. The following resident’s documents were reviewed and obtained: Admission Agreement; LIC601 Identification and Emergency Information; LIC602A Physician's Reports; Pre-placement Appraisal; Needs and Services Plan; email blast about Covid guidance including but not limited to visitation. LPA interviewed family member (FM1 & FM2), residents (R2 and R3), staff (Ruth Ocon and Resident Services Director), and conducted inspection.


.....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20210317082415
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: 02/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

Allegation: Staff left resident on the floor for expended period of time.
It was alleged that R1 fell off from bed, and was left on the floor for extended period of time. Family member (FM1) was interviewed on 3/25/21 who stated they saw on the camera they placed on R1’s room that R1 was on the floor on 3/13/21 and 3/14/21, and R1 was left unattended for 2 to 3 hours. LPA tried to obtained video footage from FM1 but was unsuccessful. LPA was not able to obtain information from R1 of what had happened on the alleged incident dates. Another family member (FM2) was interviewed on 12/01/21 who stated there were some issues but indicated caregivers are good in providing good care to the resident.

Based upon interviews conducted, and FM1 unable to provide video footage of the alleged incident, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff do not follow the admission agreement in accordance with the service plan.
It was alleged that per Admission Agreement R1 is to be checked every hour. FM1 was interviewed on 3/25/21 who stated that R1 is on an hourly check per Admission Agreement. They were verbally told R1 is on level 5 care needs; however, they do not know what is level 5. Copies of Admission Agreement and Needs and Services Plan were obtained and reviewed by LPA. Although Admission Agreement showed R1 is on level 5 based on the rate fee charge, this document and the Needs and Services Plan didn’t indicate R1 is on hourly check. Review of Appendix B-1 of Admission Agreement showed the rate charge for R1 falls under level 5. On 2/24/23. Resident Services Director was interviewed who stated that the status checks for level 5 resident is every two hours or 4 times per 8 hours shift.

Based upon interviews conducted, and records review, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

,,,,continued next on 9099C (page 3)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20210317082415
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: 02/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3
Allegation: Resident's room does not have adequate heater.
It was alleged that the heater in R1’s room does not work, and staff brought in a temporary heater which is not adequate. FM1 was interviewed on 3/25/21 who stated that R1 told FM1 that wall heater on R1’s room was not working on 3/14/21 and the staff only brought in the floor heater that day and it was not working either. LPA verified and FM1 said the wall heater was still not working but the floor heater was already working, On 3/26/21 and 12/01/21, LPA conducted inspection. LPA observed on 3/26/21 that R1’s room was vacated as R1 moved to Memory Care Unit on the night of 3/25/21. LPA observed the heater working. LPA was not able to obtain information from R1. On 3/26/21, LPA interviewed Ruth Ocon, the Executive Director during that time who stated she never received any complaint about heater not working. On 12/01/21, LPA interviewed R2 who at that time was on the room vacated by R1 stated the temperature in the room is okay and the heater is working. R3 stated the heater in R3's room is working,

Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff denied resident the right to reasonable visitations.
It was alleged that staff denied the family member visits to R1 under any condition, even though everyone in the facility is already vaccinated for Covid-19. On 3/25/21, LPA interviewed FM1 who stated that they were allowed to get inside R1's room when they were moving-in R1's furniture on 3/12/21. They were told the facility has 2 positive cases, and that they cannot visit. However, when R1's other family members went to the facility on 3/14/21, they were allowed to get in. FM1 stated there's a lot of confusion in regards to visitation, and that were not told about window and/or virtual visitations. They were only allowed to visit Tuesday, 3/16/21. LPA reviewed facility history of Covid-19 positive cases which showed a case was reported on 3/09/21, 2 days before R1 moved-in. LPA interviewed Ruth Ocon on 3/26/21 who stated when the facility has Covid case, they are not allowing visitation until Public Health clears the facility. However, when there's new admission, they are allowing the family to come inside on the day of move-in, so they can set-up the room, and move-in some stuff the resident will need.

....continued pon 9099C (page 4)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20210317082415
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: 02/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 4

The facility's side door is open, and the family members' temperatures are check Ocon also stated that R1’s niece (name she does not remember) came to visit but they asked her to leave, and explained about the facility not allowing indoor visitation. Copy of email blast dated 3/08/21 showed Ocon provided information to staff which includes visitation will be outside only. Ocon also stated an email blast was sent to residents' family members. On 12/01/21, LPA interviewed another family member (FM2) and resident R2. FM2 stated when she visits, she test for Covid. FM2 also stated she does not have any problem with visitation. R2 stated R2’s family members come and visit, and were allowed to come in. R2 also stated that staff checks the family members’ temperatures first before they are let in. LPA conducted inspection on 12/01/21, and observed a tent in the facility courtyard for outdoor visitation.

Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted. and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 15-AS-20210317082415
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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2023
Section Cited
HSC
1569.269(a)(5)
1
2
3
4
5
6
7
 §1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
1
2
3
4
5
6
7
Executive Director (ED) stated he and/or Care Service Directors will review the call button records periodically to ensure timely response. In additiionm, ED will conduct in-service training, and submit copy of training topic with attendees signatures by 2/25/23.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by:
-Based on records review and interviews. the licensee did not comply with the section above for staff not responding to residents' calls in timely manner which poses immediate health, safety and personal right risks to persons 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7