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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 08/29/2023
Date Signed: 08/29/2023 12:16:20 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
08/21/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20230821111804
FACILITY NAME:PACIFICA SENIOR LIVING OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:GARCIA, ANTHONYFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:197CENSUS: 114DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Anthony Garcia, AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff does not prevent residents room from bed bugs.
INVESTIGATION FINDINGS:
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On 8/29/23 at 11:05 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit.

During the course of investigation LPA reviewed the complaint, left a voice message for the reporting party (RP) and interviewed the facility administrator (ADM). LPA also toured Unit 115.

RP stated in the compliant that his sister lives in Unit 115 and has had bed bugs on and off for the past several months. On July 31, 2023, the Unit was given a heat treatment to eliminate the bed bugs by Orkin Pest Control. The Unit was then inspected and there were no signs of bed bugs.

***report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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 2
Control Number 15-AS-20230821111804
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: 08/29/2023
NARRATIVE
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***report continues from LIC9099***

On August 21, 2023, R1 reported to facility staff that she felt that she had new bites on her arms. Facility nurse applied hydrocortisone to the bites and informed the ADM. ADM emailed the family of the occupants of the Unit to inform them that he would be formulating a plan. ADM then called Orkin to return and inspect the Unit. Orkin returned on August 25, 2023, and treated the Unit with a chemical dusting. Upon closer inspection Orkin discovered there were felt banners on the wall of the Unit that had been removed during the heat treatment with bed bug residue on them.

On August 29,2023, Orkin the ADM met with the family of the occupants of the Unit. The Unit will be deep cleaned and then heat-treated next week.

LPA toured Unit 115 and observed Orkin technicians cleaning the Unit.

This agency has investigated the complaint alleging staff does not prevent residents room from bed bugs we have found that the complaint was 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, a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2