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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 08/30/2024
Date Signed: 08/30/2024 01:11:10 PM


Document Has Been Signed on 08/30/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 57DATE:
08/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Business office manager - Jovy CastroTIME COMPLETED:
01:15 PM
NARRATIVE
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On 08/30/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit. LPA met with business office manager Jovy Castro and explained the purpose of today's investigation.

During today's visit LPA toured chemical storage areas, observed the custodial cleaning cart, and conducted interviews. It was verbally reported to the Department's regional office in San Bruno on 08/29/2024 that a resident was found with a bottle of cleaning solution in her room. A staff person passing by the room during a resident activity observed the resident holding the spray bottle of Windex with the top spray nozzle/cap off, holding the bottle of cleaning solution and the spray nozzle in each hand. The staff person immediately retrieved the bottle from the resident and reported observations and the situation to management. Per examination of the Windex bottle it was found that there was Fabuloso cleaning solution inside the bottle, not Windex. Management staff called 911 and the resident was evaluated on site. Based on emergency responders evaluation, they recommended to not send the resident to the emergency department as the resident appeared normal and baseline. The facility contacted the power of attorney for the resident and they too agreed to not send the resident to the emergency department. Resident is on increased supervision for 72 hours as a safety precaution due to health concerns. Per interviews conducted today the resident has been eating normally and acting normally since the incident with no indications of distress. Based on interviews conducted today, cleaning staff at the facility forgot the cleaning solution in the room after cleaning and the resident was able to access the cleaning solution forgotten in their room. Staff observed the solution on the face of the resident around or near the lips, on the cheek, and on the glasses of the resident, the facility failed to keep cleaning solutions inaccessible to residents in care which poses an immediate health and safety risk.

Deficiencies are cited in accordance with California Code of Regulations Title 22 and is noted on attached LIC809D. Additional citations or penalties may be issued. LPA reviewed the report with business office manager Jovy Castro and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2024
Section Cited
CCR
87309(a)

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87309 Storage Space - (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by:
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The facility shall provide a plan of correction in writing identifying how the facility will prevent this regulation from not being met in the future. The written plan shall be received by the due date identified.
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Based on interviews conducted, a cleaning solution was left in a resident's room where they were able to access it, open it, and had some of the solution on their face. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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