019200513-12-6-2021-15-AS-KHOS-CRFPZ6-20230502114502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 12/06/2021
Date Signed: 12/06/2021 03:47:19 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
11/29/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20211129121021

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: 109	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ruth Ocon, Executive Director		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not assessing residents prior to admission.
Facility has bed bugs.
Facility has pests.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/6/2021 starting at 1:15 PM, Licensing Program Analysts (LPAs) L. Francisco and G. Clark arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Resident Care Director, Joann Nisperos and explained the purpose of the visit. LPAs later met with Executive Director, Ruth Ocon at 2:40 PM.

During the complaint investigation, LPA toured memory care, obtained information, collected documents and interviewed 5 staff and 1 resident.

Based on information obtained, facility is not assessing residents prior to admission. LPA was not provided additional information. However, LPA reviewed a sample of a new admission and observed a Preplacement, Physician Report and Care Plan completed by facility prior to resident's admission.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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 4

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
11/29/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20211129121021

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: 109	DATE:	12/06/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ruth Ocon / Anthony Garcia		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility elevator is in disrepair.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

***THIS IS AN AMENDED REPORT FROM VISIT ON 12/6/2021***

On 12/6/2021 starting at 1:15 PM, Licensing Program Analysts (LPAs) L. Francisco and G. Clark arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Resident Care Director, Joann Nisperos and explained the purpose of the visit. LPAs later met with Executive Director, Ruth Ocon at 2:40 PM.

During the complaint investigation, LPA toured memory care, obtained information, collected documents and interviewed 5 staff and 1 resident. Based on information obtained, facility elevator is in disrepair. Interview with 1 of 5 staff confirmed there is a sound of water while in the elevator is in-use.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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 4

Control Number 15-AS-20211129121021

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: 12/06/2021

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

***THIS IS AN AMENDED REPORT FROM VISIT ON 12/6/2021***

However, during an interview with staff 5 (S5), it was revealed since the elevator is 50 years old, and grand-fathered into a building code where a sump pump can be used in the elevator shaft. S5 confirmed the sound of water can be heard, but it does not affect the operation of the elevator.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20211129121021

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: 12/06/2021

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 information obtained, facility has pests and bed bugs. LPA reviewed records and observed a invoice for monthly maintenance from Clark Pest Control and a heat treatment schedule by Bay Area Bed Bugs. During LPAs tour of memory care, LPAs did not observe pests.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4