019200513-8-25-2023-15-AS-KHOS-CVSJZ8-20230918072908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/25/2023
Date Signed: 08/25/2023 05:18:56 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
08/13/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210813150529

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: 105	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Anthony Garcia/Executive Director		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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-Facility in disrepair.

-Residents left in soiled diapers for an extended period of time.

-Facility staff are not cleaning residents room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations, and close the complaint. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit.

During the course of investigation, LPA obtained copies of resident rosters and staff schedule. LPA conducted inspection including but not limited to kitchen, residents rooms, bathrooms/toilets, dining room, activity and common areas in the Assisted Living and Memory Care Units. LPA conducted interviews on 8/18/21, 12/01/21 and 8/25/23.

Allegation: Facility in disrepair.
It was alleged that the sink faucet water backs up when the water is turned on.

.....continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 3

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: 08/25/2023

NARRATIVE

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Page 2

During inspection, LPA turned on the faucets and flushed the toilets in residents rooms in Assisted Living and Memory Care Units, and didn't observe any clogging and water in the sink was observed draining properly.

Executive Director stated that no pipe broke or have issue where water backed-up. If residents flushed paper towel in the toilet, the toilet clogged and they fix the problem right away. One out of six (6) staff interviewed stated that residents may at times use the sink in the toilet to clean cups, and food scraps may cause draining problem but they take care of the problem immediately. Four out of 5 residents interviewed stated didn't have clogging issue, and 1 was not able to provide information.

Allegation: Residents left in soiled diapers for an extended period of time.
Four staff interviewed who had or still have direct contact and/or provided/providing care to the residents stated residents' diapers are changed at least 3x during shift. The other 2 staff indicated they have not observed any residents in soiled diapers.

Five residents interviewed indicated either not using diaper, can toilet on their own or use diaper and being assisted or changed by staff.

Allegation: Facility staff are not cleaning residents room.
It was alleged that residents rooms were not cleaned, and their garbage not removed.

Staff interviewed stated that rooms in Memory Care Unit are cleaned and trash taken out everyday while the the Assisted Living rooms are cleaned once a week.

One out of 5 residents interviewed was not able to provide information on the cleaning of the room.

LPA conducted inspection and although observed 2 rooms in Assisted Living unit with residents' belongings on the floor, the flooring was observed clean.

....continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 08/25/2023

NARRATIVE

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Based on information gathered, the allegations of facility in disrepair, residents left in soiled diapers for an extended period of time, and facility staff are not cleaning residents room are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted, and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

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