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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 10/24/2024
Date Signed: 10/24/2024 01:28:13 PM


Document Has Been Signed on 10/24/2024 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 102DATE:
10/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director, Anthony Garcia TIME COMPLETED:
01:45 PM
NARRATIVE
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On 10/24/24 at 1:15 pm, Licensing Program Analyst (LPA) Greg Clark conducted a case management visit pertaining to a letter received by the Oakland CCL ASC Regional Office from the facility. LPA met with Executive Director(ED), Anthony Garcia and explained the purpose of the visit.

On July 9, 2024, the Oakland CCL ASC Regional Office received from the facility a letter of intent to de-license the third floor of the physical plant and convert those units for Independent Individuals who are 55 years of age and older. The letter did not specifically request approval from CCL and had insufficient detail pertaining to how the co-mingling of Independent aged 55+ renters, and licensed RCFE Assisted Living residents, would be managed to ensure the Health & Safety of the Assisted Living residents.

LPA interviewed the ED who stated that the facility currently has seven(7) 55+ independent living residents at this time.

On 10/16/24 LPM Jeremy Fong and on 10/24/24 LPA Greg Clark and ED confirmed that the facility’s website is advertising for independent renters aged 55 and older, which constitutes a change to the Plan of Operation without having obtained approval from Community Care Licensing.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 01:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2024
Section Cited
CCR
87208(a)

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87208(a) Plan of Operation…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval.

This requirement is not met as evidenced by:
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By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement.
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Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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