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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 02/11/2025
Date Signed: 02/11/2025 12:54:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
01/29/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250129113305
FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 54DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Resident Services Director, Mary Anne Rodriguez TIME COMPLETED:
11:06 AM
ALLEGATION(S):
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Licensee is not ensuring that a comfortable temperature is maintained for resident(s) in care.
INVESTIGATION FINDINGS:
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On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted a visit to deliver a copy of amended LIC9099 and LIC9099A. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted a complaint visit to deliver the findings for the above allegation. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

Regarding the allegation, Licensee is not ensuring that a comfortable temperature is maintained for resident(s) in care, according to the reporting party, windows are left open and the second floor gets very cold.

During the investigation, LPA toured the first floor and second floor and observed all the windows closed, however according to the staff interviewed, the staff do open the windows on the first and second floor to eliminate odor. LPA observed thermostats on the first and second floor, however it was observed to not be working. It was stated by the administrator and staff interviewed that the facility does not have a functioning heating unit on the first and second floor and the facility uses portable heaters in the common areas. During the visit, LPA observed residents at the facility wearing heavy jackets and wrapped in blankets.

Based on the interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

Report is reviewed with Resident Services Director, Mary Anne Rodriguez and a copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
01/29/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250129113305

FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Resident Services Director, Mary Anne Rodriguez TIME COMPLETED:
11:06 AM
ALLEGATION(S):
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Licensee is not allowing resident in care to receive visitors in their room.
Licensee is not ensuring that residents are provided adequate sleeping accomodations while in care.
INVESTIGATION FINDINGS:
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On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted a visit to deliver a copy of amended LIC9099A. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted a complaint visit to deliver the findings for the above allegations. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

Regarding the allegation, Licensee if not allowing resident in care to receive visitors in their room, according to the reporting party, the community will not let family members visit on the second floor, instead they will bring the residents down to the first floor for visitation.

During the investigation, LPA interviewed administrator and staff. The administrator denied this allegation and indicated that family members are allowed to go to the second floor if they have family on the second floor they are visiting. According to 3/3 staff interviewed, family members who are visiting residents on the second floor are able to go to the second floor to visit and they can also request to have staff bring the residents downstairs.

Regarding the allegation, Licensee is not ensure that residents are provided adequate sleeping accommodations while in care, according to the reporting party, it was observed that residents were sleeping on the floor on the second floor. No additional information for this allegation is forthcoming. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20250129113305
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
VISIT DATE: 02/11/2025
NARRATIVE
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During the complaint visits conducted on 1/30/25 and 2/11/25, LPA toured both floors of the facility. LPA did not observe any residents sleeping on the floor on the first and second floor. LPA observed 12 residents in their wheelchairs in the main dining room/common room on the second floor with staff present. The other residents were observed to be in their bedrooms or walking in the hallways. Based on interviewed staff, no residents have been observed sleeping on the floor on the second floor.

Based on the interviews conducted and observations, the above allegations are 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, therefore the above allegation is unsubstantiated at this time.

Report is reviewed with Resident Services Director, Mary Anne Rodriguez and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20250129113305
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times.

This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan in writing indicating how to ensure a comfortable temperature is maintained at the facility.
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Based on interviews conducted, it was acknowledged that the facility does not have a functioning heating unit on both floors of the facility and the facility is using portable heaters in common areas. In addition, based on observations, LPA observed residents at the facility wearing heavy jackets and wrapped in blankets.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4