019200513-5-1-2025-15-AS-KHOS-DH9PUU-20250602113807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:56:29 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
03/18/2025 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250318163614

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: 100	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Anthony Garcia, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Wrongful Eviction

INVESTIGATION FINDINGS:

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On 5/1/2025 at 2:10pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Anthony Gracia, Executive Director, and explained the reason for the visit.

During the course of the investigation LPA interviewed staff, witnesses, resident, reviewed and obtained records.

Allegation: Wrongful Eviction

During interview with W1 it was stated that R1 was being evicted due to his financial situation had changed as of November 2024. W1 stated as of March 20, 2024, there

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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-20250318163614

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: 05/01/2025

NARRATIVE

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Continued from LIC9099.

hadn't been any additional communication with any one at the facility regarding R1's financial change. S1 stated during initial interview the facility is a private pay facility only and do not accept SSI recipients. The rates for residents are set by corporate. During S1 interview on May 1, 2025, S1 stated he had heard that R1 was receiving SSI, and inquired with R1's guardian. LPA obtained email communication between S1 and R1's guardian dated February 4, 2025, regarding resources for R1, March 17, 2025, April 7, 2025, and April 17, 2025. S1 also stated there have not been any additional notices sent for the eviction process. S1 stated he has left messages with R1's family member, guardian, and ombudsman to meet and develop a plan to guide R1.

On March 17, 2025, S1 inquired with the Oakland Regional Office regarding Provider Information Notice Summary 24-13 (PIN) and was given the incorrect information.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

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