019200513-9-8-2023-15-AS-YFLS-CWFUB4-20231009152544

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:40:44 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
08/31/2023 and conducted by Evaluator Gregory Clark

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230831080636

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: 101	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Lack of supervision resulting in resident on resident altercations

INVESTIGATION FINDINGS:

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On 9/08/23 at 11:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation 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 obtained the September staff schedule for Assisted Living, interviewed the reporting party (RP), the facility administrator (ADM) and 4 residents in the dining room. LPA also observed the lunch service.

The staff schedule shows a total of 5 staff working the day shift, 5 staff working the pm shift and 2 staff on the noc shift. Staff are assigned to different areas of the assisted living building. There are no staff assigned specifically to the dining room. ADM stated that care staff are in the dining room from time to time during meals and a med tech does rounds in the dining room dispensing medication.
***report continues on LIC9099C***

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: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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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Control Number 15-AS-20230831080636

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: 09/08/2023

NARRATIVE

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***Report continues from LIC9099***

LPA observed the lunch service with about 50 residents having lunch, 4 servers and 1 care staff. There were no incidents during the observation.

LPA interviewed 4 residents. Three of residents (R1, R2 and R3) interviewed reported that they have never seen or heard any altercations in the dining room. All 4 residents eat lunch in the Assisted Living dining room on a daily basis. R4 reported that he has on occasion heard voiced raised and some arguments happening. He has never seen anything escalate to a physical altercation.

This agency has investigated the complaint alleging lack of supervision resulting in resident-on-resident altercations. 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-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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