019200513-4-30-2024-15-AS-YFLS-D8ZV8W-20240911161322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:01:28 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
04/23/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240423100115

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: 105	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Anthony Garcia, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect of Physical Care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/30/24 at 11:15 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 the investigation LPA interview W1, S1, S2 and S3, reviewed R1’s file and toured R1’s apartment. LPA left numerous messages for the Reporting Party but never heard back from them.

R1 was admitted to the facility on 8/09/18. R1 lives in the independent side of the facility in his own apartment. R1’s apartment was observed to be clean, minimally furnished, and somewhat cluttered. LPA did observed cans of cat food in the apartment closet. Interviews revealed that R1 liked to feed the stray cats that roam the grounds of the facility.

***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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20240423100115

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: 04/30/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

***report continues from LIC9099***

Review of R1’s file revealed that R1 has a diagnosis of schizophrenia. Review of R1’s medication administration record reveled that R1 is compliant with taking his medication on a daily basis.

On 4/20/24 R1 called 911 on himself and was transported to Kaiser Hospital. R1 was subsequently moved to St. Helena Hospital for further evaluation of his mental health condition where he remains as of today. There is no discharge date at this point.

Interview with W1 revealed that he is happy with the care R1 receives at the facility and is hopeful that he can return to the assisted living side of the facility. W1 stating that R1 can be difficult, at times, to deal with and he feels facility staff do a good job dealing with R1. W1 also stated that facility staff keep him information of any issues regarding R1’s care or medical condition.

Interviews with S1, S2 and S3 revealed that R1 is sometimes non-compliant but staff can usually gain his compliance. Interviews also revealed that R1 would refuse housekeeping services for months at a time and also refuse to see his doctors. All three staff stated that although R1 had his issues, they feel they can work with him to keep him safe and healthy.

This agency has investigated the complaint alleging neglect of physical care. 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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2