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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/18/2021
Date Signed: 08/18/2021 06:13:33 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
08/13/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210813150529
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: 83DATE:
08/18/2021
UNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Ruth Ocon.Executive Director TIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility does not provide a safe and healthful environment for the resident.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegation. LPA met with Exectuive Director Ruth Ocon and explained the purpose of the visit. LPA also met with Resident Services Director-LVN Joann Nisperos and Memory Care Director Ebony Foi.

LPA conducted inspection with Joann Nisperos. LPA inspected rooms in assisted living section of the facility and checked the generator in the store room. LPA observed protruding cables in the hallway outside residents rooms, and pails of paint and Pennzoil close to the running generator. Therefore, the allegation is substantiated.

.....continued on 9099C
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: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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
Control Number 15-AS-20210813150529
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: 08/18/2021
NARRATIVE
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Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan correction due date may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Ruth Ocon.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form 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: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210813150529
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: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
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.

This requirement is not met as evidenced by:
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Executive Director called and left message to facility's maintenance director to address/clear the issues while LPA is still at the facility. Pictures to be submitted by 8/19/2021.
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-Based on inspection and observation, the licensee did not comply with the section cited above. LPA observed cables in the hallway and pails of paint and Pennzoil close to the running generator. These pose immediate safety 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: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4