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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 02/24/2023
Date Signed: 02/24/2023 06:25:17 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
11/23/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211123105807
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: 99DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anthony Garcia/Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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-Facility is short staffed.

-Facility has pests.

-Facility is not conducting fire drills as required.

-Facility is unsanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation 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 roster and staff schedule Interviews and inspection were conducted.

Allegation Facility is short staff.
It was allleged that facility is short satt. On 12/01/21. LPA interviewed Ruth Ocon, Executive Director at the time complaint was received. Ocon stated that she has to left go two staff for violation of company rules and policies and in the process of hiring. LPA also interviewed S1 and S2 on 12/01/21. S1 stated she's covering both Assisted Living and Memory Care units while facility is in the process of hiring. S2 who is on the unit not covered by the 2 staff who were let go, stated that she works 7 days a week due to short stafing as a result of people leaving.
.....continued on 9099C (page 2)
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-20211123105807
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
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Page 2
On this day, 2/24/23, Anthony Garcia stated that they are in the process of hiring Memory Care Services Coordinator.

Based upon interviews, ,the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Facility has pests.

It was alleged that rats are being found in the dining room and kitchen, and have chewed through the boxes of emergency food supply stored in the basement.

On 12/01/21, LPA conducted inspection, and observed mouse droppings in the food storage, and canned food with small bites on the labels LPA interviewed staff S1 on that same day who stated that food supplies has to be moved from large to small storage due to rat infestation.

Based upon interview and inspection, the Department has found 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.



Allegation: Facility is not conducting fire drills as required.

It was alleged that the facility has not conducted a fire drill in over 6 months.


On this day. 2/24/23, LPA obtained copies and reviewed fire drill records in facility's file which showed dated 9/22/22, 10/27/22 and 1/27/23. LPA also interviewed Resident Services Director Joanne Nisperos who stated they only started doing fire drills when Anthony Garcia became the Executive Director.

Based upon interview and record review, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
...continued 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: 2 of 7
Control Number 15-AS-20211123105807
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
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Page 3

Allegation: Facility is unsanitary
It was alleged that trash is overflowing in all of the buildings, in the stairwells and the trash chutes.

On 12/01/21, LPA conducted inspection, and observed on the lowest level on the stairwell in Memory Care unit a shopping bag with soiled diapers. used disposable gloves and soiled pads.

Based upon inspection, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.

Deficiencies and plan and proof of corrections 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: 3 of 7
Control Number 15-AS-20211123105807
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 B
03/24/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed ...........
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Executve Director stated they are in the process of hiring memory care coordinator. Proof that this postiion is filled-up tp be submitted by 3/24/23.
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-This requirenent is not met as evidenced by:
-Based on interviews, the licensee did not comply with the section above for not having sufficient staff.
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Type B
03/03/2023
Section Cited
CCR
87303(a)
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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.
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Corrected.
Faciliy hired pest control company. Proof of service obtained by LPA on this same day, 2/24.23.
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-This requirement is not met as evidenced by:
-Based on inspection, observation and inteview, the licensee did not comply with the section above for having rat infestation.
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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: 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: 4 of 7
Control Number 15-AS-20211123105807
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 B
03/03/2023
Section Cited
CCR
87705(l)(8)
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87705 Care of Persons with Dementia
(l):(8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
-This requirement is not met as evidenced by:
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Executive Diector (ED) to have fire drill conducted and submit proof by 3/03/23.
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-Based on records review and interview, the licensee did not comply with the section above for not having completed fire drills which poses potential safety risks to persons in care.
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Type B
03/03/2023
Section Cited
CCR
87303(a)
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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.
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The garbage was removed on the day LPA observed.
In addition, ED will in-service the staff and submit by 3/03/23.
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-This requirement is not met as evidenced by:
-Based on inspection and observation, the licensee did not comply with the section above for trash in the stairwell which ppsed potential health and personal rights risks to persons 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: 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: 5 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
11/23/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20211123105807

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: 99DATE:
02/24/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anthony Garcia/Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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-Facility is not maintained properly.

-Staff allow resident to smoke inside the facility.-

-Staff are not properly trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to contine the investigation and close the complaiint. 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 and staff schedule Interviews and inspection were conducted. Copies of invoice and/or proof of servie from fire protection company was obtained.

Allegation: Facility is not maintained properly.
Reporting party stated that the sprinkler system has not been inspected for over 6 months, It was also alleged that the front door lobby won't lock and broken that it won't stay openwhen residents in wheelchair will go through it. Sprinkler system was not serviced for at elast 6 months and kitchen vents not cleaned for over 9 months.
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: 6 of 7
Control Number 15-AS-20211123105807
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
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On 12/01/21, LPA interviewed Ruth Ocon, the Executive Director at that time who stated that front door lobby was not locking about 6 months ago from the day of interview. It was fixed and worked for about a month and got broken again. On that same day and on this day, 2/24/23. LPA tested the door by pushing the bar for the disabled to push to open the door, and observed was working properly.

On 12/01/21, staff was interviewed who stated that it's been working and that she was told that the door is locked at night. On 2/24/23, Anthony Garcia was interviewed who stated that the door has an alarm that is automatically activated at certain hour at night. Copy of record obtained showed that the sprinkler system, kitchen hood system, and exhaust were serviced on 10/17/22. LPA inspected the kitchen vents and hood on 2/24/23 which were observed clean.

Based on interviews, records review 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.

Allegation: Staff allow resident to smoke inside the facility.
It was alleged that there's a resident (R1) in AL unit that constantly smoke inside her room. On 12/01/21, LPA interviewed R1 who stated she smoked inside her room, but when the staff discovered, she quit smoking.

Allegation: Staff are not properly trained.
It was alleged that staff do not have the required training such as dementia training and mandated reporter training. On 2/24/23, LPA asked for staff records and copies of staff training, ED provided copies of training that were download from the computer, however, records do not show the number of required training.

Based on records review 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 citation issued. 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