019200513-8-21-2020-15-AS-HHUL-BT9PNM-20200908112810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/21/2020
Date Signed: 08/21/2020 03:24:30 PM

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
10/10/2019 and conducted by Evaluator Rolanda Pitcher

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20191010151323

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: 131	DATE:	08/21/2020
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Sante Dhakal		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff failed to protect the residents from harm.

INVESTIGATION FINDINGS:

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On 10/17/19 at 9:25 am, Licensing Program Analyst, (LPA) Rolanda Pitcher conducted an investigation regarding the above mentioned allegation. LPA met with Resident Services Director, Sante Dhakal and discussed the purpose of this visit. On 10/17/19, LPA conducted interviews with S2, S3, S4.

LPA learned R1, R2 can be aggressive particularly towards one another. S1 stated aggressive behavior is not uncommon with some Dementia residents, denies sexual activity. S1 stated R2 can be territorial when it comes to sitting in the chair R2 prefers which is near a patio door. During the course of this investigation no substantial evidence was found to support residents lack proper supervision. LPA found no evidence R1, R2 poses harm to residents or staff.

Based on interviews with staff, LPA found no evidence that supports R2 poses a sexual threat way towards female residents. Furthermore, W2 stated R1 is friendly towards all females, staff or visitors.

Report continued on LIC 9099

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020

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-20191010151323

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: 08/21/2020

NARRATIVE

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On 10/17/20, LPA was provided a copy of the incident report regarding an incident that happened on 9/28/20 faxed to Community Care Licensing reporting "resident on resident aggression."

R3 pushed R4 down resulting in a slight contusion. LPA has determined although an act of aggression did happened there is not enough evidence to support staff failed to protect residents in care.

Based on R3 record review R3 did not have a history of aggression towards residents or staff.

The Department has investigated the allegation "facility staff failed to protect the residents from harm." LPA conducted record review and staff and witness interviews and have determined this complaint unsubstantiated.

A finding that the complaint 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.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC9099 (FAS) - (06/04)

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