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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 01/04/2022
Date Signed: 01/04/2022 12:01:39 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
01/03/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220103102247
FACILITY NAME:PACIFICA SENIOR LIVING OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:AMANDA M DOMINGUEZ NORTHFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:197CENSUS: 109DATE:
01/04/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ruth Ocon - Administrator & Joan Nisperos - nurse TIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have heat
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/04/2022 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct complaint investigation for the allegation above. LPA met with Administrator Ruth Ocon and nurse Joan Nisperos.
LPA toured the facility to check random bedrooms and common areas, LPA observed facility thermostat was set up for 80 degrees Fahrenheit. LPA observed that residents was provided with small heaters and extra blankets. LPA conducted interview with staff and residents, based on the interview, on 12/29/2021 staff noticed 3 bedrooms that do not have electricity and the circuit breaker was turning on and off, Administrator then called electricians to assess the situation, on the same day there was a planned power shut off for atleast 2-3hrs to fix electrical circuit .
Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies are being cited on this date.
Exit interview conducted with Joan Nisperos. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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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