415601046-5-4-2021-14-AS-KHOS-C2VNMC-20210510103454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 05/04/2021
Date Signed: 05/04/2021 05:08:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210303162421

FACILITY NAME:	PACIFICA SENIOR LIVING MISSION VILLA		FACILITY NUMBER:	415601046
ADMINISTRATOR:	NICKOLAI, KAREN		FACILITY TYPE:	740
ADDRESS:	995 E MARKET ST		TELEPHONE:	(650) 756-1995
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	60	CENSUS: 58	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Karen Nickolai,		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Resident sustained severe dehydration while in care.
Staff did not communicate with authorized representative regarding resident's change of health conditions.

INVESTIGATION FINDINGS:

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On 05/04/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. Because of COVID-19 and social distancing measures, LPA Filouane called and spoke to Administrator Karen Nickolai over the phone and delivered the findings.

During the investigation, the Department conducted interviews, reviewed and collected the client's medical records, and hospice documents.

Regarding the allegation concerning a resident sustaining severe dehydration while in care, the Department found no evidence of severe dehydation after reviewing the resident's medical records. The Department confirmed the resident was discharged from the medical center with mild dehydration. The resident's overall health has been reported to be progressively declining, according to the Department's investigation. After review, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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 14-AS-20210303162421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA	FACILITY NUMBER: 415601046
	VISIT DATE: 05/04/2021

NARRATIVE

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Regarding the allegation of staff not communicating with authorized representative regarding the resident's change of health conditions, the Department's investigation found no evidence to support this allegation after review of the resident's medical records at the medical center, as well as the initial hospice care assessment. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with the Administrator over the phone. The Administrator will receive this LIC9099 report through email or mail to sign and then will email or mail the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

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