019200513-8-10-2023-15-AS-YFLS-CUPVJC-20230814162830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:24:58 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
04/03/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230403155305

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:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff failed to change residents’ diapers in a timely manner
Staff not repositioning resident
Resident had unexplained weight loss
Facility elevator is inoperable
Resident fell resulting in a bruise

INVESTIGATION FINDINGS:

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On 8/10/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a complaint investigation and deliver findings in regard to the allegations above. LPA met with Anthony Garica, Administrator (ADM) and explained the purpose of the visit.

During the course of investigation, LPA interviewed the complainant (RP), R2’s family, the facility's administrator, the Resident Service Director (RSD) and S1. LPA toured the memory care unit with ADM and RSD. LPA was unable to obtain any additional information from R2’s family.

While in the memory care unit LPA observed R2 being feed her lunch by S1. S1 stated that she works the day shift in memory care 5 days a weeks and feeds R2 her lunch every day. S1 also stated that it is sometimes hard to get R2 to eat as she has a poor appetite. If R2 doesn’t eat her lunch S1 brings her a snack or Ensure later in the afternoon.
***reort continues on LIC9099C***

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: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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-20230403155305

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: 08/10/2023

NARRATIVE

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***report continues from LIC9099***

Staff failed to change residents’ diapers in a timely manner.

RSD stated that residents in memory care that are incontinent are checked every 2 -3 hours and changed as needed. This is not documented as it is part of the daily schedule for care givers.

Staff not repositioning resident

R2 is wheelchair bound and spends most of her day in her wheelchair. When R2 needs to be changed R2 is taken by staff to her bedroom and placed in her bed to be changed. RSD stated there is no record of R2 having any pressure sores.

Resident had unexplained weight loss.

R2 weighed 134.8 lbs. on 3/3/22 and 127 lbs. on 3/01/23 for a weight loss of 7.8 lbs. which is 5.7 percent. This is with-in the normal range of a person in their late 80’s. R2 also takes Ensure daily to help with weight maintenance.

Facility elevator is inoperable.

ADM reported that the memory care elevator was out of service for a period of 6 – 8 weeks while the elevator was getting an upgrade. The elevator was back in service on 4/04/23.

Resident fell resulting in a bruise.

RSD reported that R2 bruises easily due to the medications she takes. R2 is a fall risk but hasn’t had a fall in over 1 year.

This agency has investigated the complaints alleging staff failed to change residents’ diapers in a timely manner, staff not repositioning resident, resident had unexplained weight loss, facility elevator is inoperable, and resident fell resulting in a bruise. We have found that the 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, 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: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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