019200513-5-12-2023-15-AS-YFLS-CRVRXN-20230516132502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 05/12/2023
Date Signed: 05/12/2023 01:06:05 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
05/02/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230502151950

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: 109	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility has mold
Staff failed to provide a safe and comfortable environment for residents

INVESTIGATION FINDINGS:

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On 5/12/23 at 12:10 p..m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit.

During the course of investigation, LPA toured the facility including but not limited to the common areas, kitchen, and 1 apartment. LPA also interviewed the reporting party (RP), 3 staff (S1, S2 and S3) and 2 residents (R1 and R2). Sample size was limited as this complaint happened in 2020.

Based on observations and intrviews conducted the allegation that the facility has mold and failed to provide provide a safe and comfortable environment for residents is unsubstantiated. 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 and a copy of this report provided.

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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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