019200513-10-23-2020-15-AS-KHOS-BUUMQ2-20201029094801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 10/23/2020
Date Signed: 10/23/2020 05:26:01 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
05/22/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200522094324

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: 108	DATE:	10/23/2020
		UNANNOUNCED	TIME BEGAN:	04:40 PM
MET WITH:	Amanda North, Executive Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident's room is infested with bed bugs.

INVESTIGATION FINDINGS:

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On Friday, October 23, 2020 at 4:40 PM, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility unannounced to deliver findings on the allegation listed above. LPA spoke with Executive Director (ED), Amanda North via Facetime. Due to the Shelter in Place set forth by the Governor, LPA conducted tele-visit on deliverance of this complaint.

During the course of the investigation, LPA conducted interviews with Reporting Party (RP), staff (S1, S2, S3), and witness (W1). In addition, LPA reviewed medical records, vector control records and other pertinent records.

Allegation-Resident's room is infested with bed bugs. When LPA interviewed RP, RP stated that R1 complaint of bites behind neck and leg from beg bugs inR1's room. RP stated that R1 seek medical attention regarding bed bugs.

Continuation on LIC 9099 C, Page 1 of 2 Complaint Investigation Report

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020

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-20200522094324

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: 10/23/2020

NARRATIVE

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Page 2 of 2 Complaint Investigation Report

When LPA interviewed staff (S1-S3), all staff denied R1 room had any bed bugs and no incident report was file for R1's room for bed bugs. When LPA interviewed W1, W1 stated that R1's room did not have any bed bugs upon each inspection. When LPA reviewed medical records, R1 was seen on 01/07/2020 with a chief complaint for bed bugs, Physician did not notate any signs of bed bug bites. When LPA reviewed records from Vector Control Health Inspector for the visits on 01/06/2020, 01/10/2020, 02/03/2020, 02/05/2020, 02/19/2020, and 02/20/2020, no bed bugs was discovered in R1's room or bites seen on R1 during each visit.

Therefore, this is an isolation complaint only for R1's room regarding bed bugs. Based on interviews conducted and records reviewed, LPA has found this complaint to be 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.

Exit interview conducted with Executive Director, Amanda North. Copy of report provided via email PDF.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020

LIC9099 (FAS) - (06/04)

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