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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:58:18 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: 55DATE:
09/16/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Business office manager - Jovy CastroTIME COMPLETED:
03:00 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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On 09/16/2024, Licensing Program Analyst (LPA) Jaime Vado made an unannounced subsequent complaint investigation visit. The purpose of this visit is to provide additional citations related to the already substantiated complaint allegations investigated on and findings were delivered on 08/20/2024.

Upon further review, it was determined additional citations are needed in regards to the allegation findings delivered on 08/20/2024 where a citation was made and delivered on that date. It was found that the facility is responsible for the observation of the resident's change in food and water intake as well as the change in mental and physical changes as an indicator to health conditions discovered as a result of being sent to the emergency room. The resident lost weight while at the facility from 120lbs to 111lbs as well as was dehydrated as found during an emergency room visit made by the resident. Additionally there was a change in the resident's mental condition also found at the hospital These items pose an immediate health and safety risk to residents in care.

As already stated these same allegations were substantiated on 08/20/2024 but additional citations are being issued on this day. Additional citations are cited on the attached LIC9099D.

Report is reviewed with Jovy Castro - Business office manager.
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 2
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: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2024
Section Cited
CCR
87101(c)(3)(H)
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87101(c)(3)(H) "Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (H) Monitoring food intake or special diets. This regulation 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 while at the facility. It is not apparent that regular food intake records were being made to track any changes in food intake. Some meals may have been missed or the resident not receiving enough food caused the resident to lose weight at the facility from 120lbs to 111lbs at time of weighing at the emergency room. This finding poses an immediate health a safety risk to the resident in care.
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Type A
09/17/2024
Section Cited
CCR
87464(f)(5)
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87464 Basic Services(f)(5) - (f) Basic services shall at a minimum include: (5) Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident. This regulation 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 records reviewed, the resident was found to have a condition as a result of dehydration which resulted in the resident needing fluids provided intravenously while at the hospital. Additionally there was a change in the resident's mental condition also found at the hospital . This finding poses an immediate health a safety risk to the resident 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: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2