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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 08/20/2024
Date Signed: 09/16/2024 02:57:30 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
05/14/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240514090937
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: 59DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Business office manager - Jovy CastroTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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- Due to staff neglect resident lost weight
- Due to staff neglect resident was dehydrated
INVESTIGATION FINDINGS:
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*** This amended report was created in error. No changes are made to this report***

On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the complaint alletgations received. LPA met with business office manager Jovy Castro and explained the purpose of today's visit.

During the investiation, LPA conducted interviews and reviewed documets pertinent to the investigation such as resident records and medical information. Per the medical documentation reviewed, the resident did lose weight during their time at the facility. Upon admission the weight is documented as 120lbs but after being weighed in a hospital setting the resident weighed 111lbs indicating the weight loss after approximately five weeks. Additionally, the resident was diagnosed with a condition while at the hospital which is a result of dehydration. Upon hospitalization the resident was provided fluids intravenously to aid in hydration. These allegations are substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is discussed with Jovy Castro and a copy of this report is provided on this day.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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 3
Control Number 14-AS-20240514090937
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: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requriement has not been met as evidenced by:
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Licensee shall conduct staff training and submit a written plan outlining how this violation would be avoided in the future. Must be submitted to the licensing office by due date, failure to correct this deficiency by due date may result in a civil penalty.
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Based on documentation reviewed, the resident lost weight going from 120lbs to 111lbs during the resident's stay at the facility of approximately 5 weeks, additionally the resident was found to have a condition as a result of dehydration which resulted in the resident needing fluids provided intervenously while at the hospital. These finding pose an immedate health a safety risk to the resident in car.
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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: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
05/14/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240514090937

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: 59DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Business office manager - Jovy CastroTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
- Staff did not seek timely medical care for resident
- Staff did not notice change in residents condition
INVESTIGATION FINDINGS:
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On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the complaint alletgations received. LPA met with business office manager Jovy Castro and explained the purpose of today's visit.

During the investiation, LPA conducted interviews and reviewed documets pertinent to the investigation such as resident records and medical information. Per interviews conducted with staff and the documentation reviewed LPA wasn't able to determine if there was an observable change in the resident that would alert staff to seek medical care. LPA could not prove or disprove that the facility staff did not seek timely medical care or the staff not noticing a change in the residents condition. These allegations are unsubstantiated.

Report is discussed with Jovy Castro and a copy of this report is provided on this day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 3