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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 09/23/2024
Date Signed: 09/23/2024 04:14:05 PM


Document Has Been Signed on 09/23/2024 04:14 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: 55DATE:
09/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Business office manager - Jovy CastroTIME COMPLETED:
04:15 PM
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On 09/23/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - deficiencies visit. LPA met with Jovy Castro and explained the purpose of todays visit.

During an investigation conducted in relation to complaint # 14-AS-20240514090937, LPA discovered that the director of memory care was handing out medication to residents in care due to a shortage of med-techs at the time before she received full training regarding medication passing. Per interviews conducted with staff it was discovered that the training was conducted, but did the memory care director not pass the medication handling/med-tech test to receive her certification when LPA questioned the staff regarding the certification and other items related to the original complaint. This poses an immediate health and safety risk to residents in care.

A citation is being issued on this day on the following LIC809D.

Report is reviewed with Jovy and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
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 09/23/2024 04:14 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: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
HSC
1569.69(a)(5)

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1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (5) To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee’s comprehension of, and competency in, the subjects listed in paragraph (4). This requirement has not been met as evidenced by:
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The facility shall develop a plan of correction to show how that the facility will have all staff handing out medications fully trained who pass out medications and have competed the examination regarding such training. Plan shall be submitted to the department by due date.
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Based on a complaint investigation conducted in relation to complaint # 14-AS-20240514090937, it was discovered that the memory care director was passing medications to residents in care but did not pass the examination regarding med-tech training. 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: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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