019200513-11-30-2020-15-AS-KHOS-BVWQ28-20201202104644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 11/30/2020
Date Signed: 11/30/2020 04:13:06 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
06/01/2020 and conducted by Evaluator Celia Phomphachanh

COMPLAINT CONTROL NUMBER: 15-AS-20200601121752

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:	03:20 PM
MET WITH:	Amanda North, Executive Director		TIME COMPLETED:	03:53 PM

ALLEGATION(S):

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Staff did not report incident regarding resident to the authorized representative.
Staff did not seek emergency medical services for resident.
Staff failed to properly supervise resident to prevent behavior that poses a risk to other residents in care.

INVESTIGATION FINDINGS:

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On Monday, November 30, 2020, Licensing Program Analyst (LPA) C. Phomphachanh called facility to deliver findings for the complaint allegations. LPA spoke with Administrator, Amanda North via phone call. Due to the Executive Order, Shelter in Place, LPA was not able to deliver findings in person.

During the course of the investigation, LPA conducted interviews with Reporting Party (RP), Power of Attorney (POA), witness (W), and staff (S). In addition, LPA collected pertinent documents.

For the allegation: Staff did not report incident regarding resident (R1) to the authorized representative. RP stated that no one contact RP about incidents with R1. When LPA interviewed S1, S1 stated that incidents are reported to Power of Attorney (POA) listed on records upon Admission Agreement. When LPA interviewed POA, POA did confirm that facility does notify POA with incidents with R1. LPA reviewed records, POA is listed as contact person and confirmed POA was the person who assist with admitting R1 to the facility. Therefore, LPA unsubstantiated this allegation.

Continuation on LIC 9099 C - Page 1 of 2 Compliant 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)

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Control Number 15-AS-20200601121752

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

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Continuation- Page 2 of 2 Complaint Investigation Report

For the allegation: Staff did not seek emergency medical services for resident. RP stated that facility did not see medical services when R1 fell or contact hospice nurse. When LPA reviewed incident report for this complaint, on 06/07/2020, R1 was taken to Sutter Health. However, on 05/25/2020, R1 was not aware of any injuries, hospice and POA informed, this incident was not related to a unwitnessed fall. Therefore, LPA unsubstantiated this allegation.

For the allegation: Staff failed to properly supervise resident to prevent behavior that poses a risk to other residents in care. RP indicated that R1 was grabbed on the chest by another resident. When LPA interview RP, RP stated that R1 went out for a walk. When RP and staff heard loud noise, both went to check and assist with R1 and another resident. When LPA interviewed S2, S2 stated that staff assist immediately when incident occurred. Staff tried to prevent another resident from continuing to grab R1. Due to the intervention by staff and RP, LPA there was not sufficient proof that staff failed to properly supervise resident while R1 left out the door for a walk. Therefore, LPA unsubstantiated this complaint.

Based on interviews conducted and records reviewed, the Department has found these 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 Executive Director, Amanda North. Copy of report given 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)

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