019200513-11-30-2020-15-AS-KHOS-BVWQEU-20201202110656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 11/30/2020
Date Signed: 11/30/2020 12:08:20 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
09/23/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200923100527

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: 105	DATE:	11/30/2020
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Amanda North, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is infected with rodents.

INVESTIGATION FINDINGS:

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

On Monday, November 30, 2020, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility to deliver findings to the above allegation. LPA spoke with Administrator, Amanda North. Due to the Executive Order, Shelter in Place, LPA conducted a phone call to deliver the findings.

During the course of the investigation, LPA interviewed Reporting Party (RP), staff (S), Vector Control Biologist (VC) and reviewed pertinent documents.

When LPA interviewed Reporting Party (RP), RP stated that the facility has bed bugs in various rooms that has not been taken care of. RP stated that RP has current photos which RP did provide to LPA. In addition, RP indicated that staff has seen rodents in the kitchen area. When LPA interviews S1, S1 stated that the facility has pest control visits on monthly visit. When S4 was interviewed, S4 confirmed the bed bugs in specified rooms to LPA.

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

Substantiated

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: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

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 5

Control Number 15-AS-20200923100527

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: 11/30/2020

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

Continuation Page 2 of 2, Complaint Investigation Report

On 09/25/2020, LPA conducted unannounced tele-visit with S1, LPA observed kitchen to be free and clear of rodents. Perishable foods are kept in a large refrigerator on racks with dates on box. Meats and other proteins were stored in the freezers. Non-perishable foods were stack on racks with no marking. However, when LPA observed various room for bed bugs, LPA confirmed live bed bugs with casting on chair in a resident room. LPA confirmed exact lawn chair with photo LPA received from RP. After the tele-visit was completed, LPA informed S1 to have all rooms in floor 2 observed for bed bugs. Later, various rooms were identified to be infested with bed bugs.

Additionally, on 09/25/2020, LPA contacted Alameda Vector Control about the bed bugs issue at the facility. LPA forward the various rooms identified to have bed bugs. On 11/05/2020, Vector Control confirmed the multiple rooms were infested. S1 was contacted by Vector Control and LPA and informed that their heating system used to control the infestation of bed bug is not working. Facility will need to hire a professional to control the bed bug issue. Vector Control has sent a letter to Property Owners and Management about the inspection findings regarding the presence of vermin is a serious and creates health concerns.

Based on interviewed conducts, records received, and observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

California Code of Regulations Title 22, Regulation 87303 Maintenance and Operation is being cited on LIC 9099 D. Civil Penalties may be acceptable, if not cleared by Plan of Correction Date.

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

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
09/23/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200923100527

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: 105	DATE:	11/30/2020
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Amanda North, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is serving contaminated food to residents.
Staff do not ensure resident's wound care needs are met.

INVESTIGATION FINDINGS:

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

On Monday, November 30, 2020, Licensing Program Analyst (LPA) C. Phomphachanh contacted facility to deliver findings to the above allegation. LPA spoke with Administrator, Amanda North. Due to the Executive Order, Shelter in Place, LPA conducted a phone call to deliver the findings.

During the course of the investigation, LPA interviewed Reporting Party (RP), staff (S) and reviewed records.

When LPA interviewed RP, RP stated that the facility staff has reported rodents in the kitchen area and there are droppings in common area of the facility and the kitchen. When LPA interview S1, S1 stated that foods are stored properly and no known issues of rodents. S1 indicated that facility undergoes monthly pest control checks. LPA reviewed staff training records, all staff has been trained with food handling and storage.

Continuation on LIC 9099C - 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: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20200923100527

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: 11/30/2020

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

Continuation Page 2 of 2 Complaint Investigation

During a tele-visit conducted on 09/25/2020, LPA observed the kitchen area to be closed to the COVID-19 protocol and guidelines. Kitchen area and stored foods areas were clean and clear of droppings. Perishable and non-perishable were kept on racks or in the refrigerator racks within regulatory guidelines. LPA did not observe any bites or rip bags on food items. Therefore, this allegation is unsubstantiated.

Allegation: Staff do not ensure resident’s wound care needs are met.

When LPA interviewed RP, RP stated that RP was informed facility staff does not provide the needs for resident’s wound care. LPA reviewed records of residents under wound care and there were 6 residents who received wound care under a home health agency from Kaiser, BayPoint and Ace. Per S1, facility does not care for the wound of residents. It is the resident’s responsibility and how home health orders are for the Physician’s Order. So, depending on the resident’s order, is how the wound care is changes. However, if attention is needed immediately, home health or hospice will be contacted before going to Emergency Room. Due to the fact that the facility admits they do no provide care for wound care but will seek immediately attention to provider or other medical services, this allegation is unsubstantiated.

Based on interviews conducted, tele-visit, and records reviewed, LPA found the above allegations to be unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20200923100527

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/14/2020 Section Cited CCR 87303(a)(1)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...procedures for the safety and well-being of residents, employees and visitors. (1).. shall be maintained in a clean, sanitary, and odorless condition.	1 2 3 4 5 6 7	Administrator will hire a professional pest control to come in the facility to assist with the pest issue. Administrator will submit a copy of receipt and date/time as proof and have a monthly professional pest control inspection. A log will need to be kept. First inspection will have to be completed by POC date 12/14/2020.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on observation and tele-visit, facility has bed bugs in various rooms in Assisted Living (main building), which poses a potential health and safety risk with residents in care.	8 9 10 11 12 13 14
HSC	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 5