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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:22:50 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
04/24/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240424121204
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: 52DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Services Director, Mary Anne RodriguezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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-Due to lack of supervision, resident had an unwitnessed fall resulting in a fractured hip
-Staff did not seek timely medical care for resident
INVESTIGATION FINDINGS:
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On Novemember 6, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

Regarding the allegations received, due to a lack of supervision a resident had an unwitnessed fall resulting in a fractured hip, and staff did not seek timely medical care for a resident, according to the reporting party, on 4/8/24 at around 6:10am, Resident 1 (R1) was found sitting cross-legged on the bathroom floor. It was reported to the responsible party by med-tech that R1 had an unwitnessed fall, however, there were no injuries and R1 was able to stand and walk. Facility staff notified the responsible party that staff would observe R1 and notify the responsible party if there were any changes in condition or if hospitalization was required. Facility staff did not call and update the responsible party after the incident was reported to him/her at 10am. According to the reporting party, on 4/9/24 at 11am, R1 was observed sitting in a wheelchair and when the responsible party touched R1’s leg, R1 screamed. At this time, the responsible party felt that R1 should be transferred to the hospital, however, the med-techs seemed like they did not want to call an ambulance and kept suggesting that the responsible party should drive R1 to the hospital to save money. R1 was taken to Kaiser, and it was confirmed that R1 had a fractured hip. In addition, the reporting party indicated that the facility was not being truthful regarding R1’s condition. R1 may have had a fractured hip and was in pain from the injury for hours and no action would have been taken if the responsible party did not address R1’s pain. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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 4
Control Number 14-AS-20240424121204
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: 11/06/2024
NARRATIVE
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Regarding the allegation, due to lack of supervision, a resident had an unwitnessed fall resulting in a hip fracture, the Department reviewed documents and interviewed staff and residents. Based on documents reviewed and interviews conducted, R1’s unwitnessed fall was due to inadequate preventative measures and inaccurate assessments. The former resident service director inaccurately assessed R1, listing R1 as able to ambulate independently despite other documents stating R1 needed support. Based on staff interviews conducted, staff provided differing answers on whether R1 was a fall risk. In addition, according to the memory care director, it was noted that despite paperwork identifying R1 as a fall risk, there was no individualized fall prevention plan for R1, and short staffing led to the lack of supervision. Furthermore, the facility failed to follow up on the recommendation from R1’s responsible party for a walker.

Regarding the allegation staff did not seek timely medical care for a resident, during the investigation, the Department reviewed documents and interviewed staff and residents. According to the staff interviewed, on 4/8/24 at around 6:10am, care staff assisted R1 into a wheelchair after finding R1 sitting on the bathroom floor. According to the care staff, it was noted that R1 was experiencing pain in his/her right leg or hip and called R1’s responsible party. Based on interviews, R1 was observed moaning and grimacing in pain when R1 moved his/her leg, however, staff attributed the pain to his/her old age and felt that 911 was not necessary. According to the memory care director, it was acknowledged that she was informed about the incident, however, did not follow up on R1’s status due to being busy with other duties. In addition, according to the med-tech who worked at night on 4/8/24 and in the morning on 4/9/24, it was admitted that after becoming aware of the incident on 4/8/24, he/she did not check on R1 on both days because she was busy. Furthermore, the med-tech indicated that 911 should have been called but they did not. Staff admitted to R1 being in pain but waited for the responsible party to come and visit. The lack of communication between staff and the short staffing at the facility delayed R1 from being sent to the hospital timely.

Based on the investigation, 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.

AN IMMEDIATE CIVIL PENALTY OF $1,000 IS ASSESSED TODAY: $500 FOR THE VIOLATION RESULTING INTO INJURY TO A RESIDENT AND $500 FOR THE VIOLATION AS STAFF DID NOT SEEK TIMELY MEDICAL ATTENTION FOR A RESIDENT. ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49.

Report is reviewed with Resident Services Director, Mary Anne Rodriguez and a copy is provided with appeal rights. A copy of civil penalties are provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20240424121204
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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
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 requirement is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing on how to ensure staff provide proper care and supervision to all residents. Plan must include training, staffing, observation of resident, addressing changes in condition. Plan shall be submitted to CCLD by 11/7/24.
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Based on documents reviewed and interviews conducted, R1 was fell and was found on the bathroom floor and facility staff failed to ensure care and supervision was provided as documents reviewed identified R1 as fall risk, however there was no individualized fall prevention place for R1. In addition, based on staff interviewed, due to short staffing, there was a lack of supervision.
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AN IMMEDIATE CIVIL PENALTY OF $500 WAS ASSESSED FOR VIOLATIONS THAT RESULTED IN SICKNESS OR INJURY TO A RESIDENT IN CARE.
Type A
11/07/2024
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care.

This requirement is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing addressing how to seek timely medical attention. Plan shall include staff training, staffing, reassessments, individualized care plans for residents.
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Licensee failed to perform care and supervision to the resident to address the care need of a resident who fell and had a change in condition. According to staff interviews, R1 was experiencing pain in his/her right leg or hip, and called R1’s responsible party, however, did not feel that calling 911 was necessary due to R1’s old age even though staff observed R1 moaning and grimacing in pain when R1 moved his/her leg. Furthermore, based on interviews conducted and file reviewed, it was noted that R1 was at fall risk and med-techs interviewed indicated that 911 should have been called but they did not. Nevertheless, R1 was complaining and observed by staff of having pain and the facility did not seek medical attention for R1 which poses an immediate health risks to residents in care.
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Civil penalty in the amount of $500 is being assessed today as the failure to arrange medical treatment for Resident 1 (R1) after an incident that resulted in a fractured hip.
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) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
04/24/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240424121204

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: 52DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Services Director, Mary Anne RodriguezTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
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-Staff left resident in dirty clothes
INVESTIGATION FINDINGS:
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On November 6, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Resident Services Director, Maryanne Rodriguez and explained the purpose of the visit.

Regarding the allegation that staff left resident in dirty clothes, according to the reporting party, Resident 1 (R1's) clothes were stained, tattered and dirty. During the investigation, LPA interviewed residents and staff. LPA attempted to interview five residents, however due to their dementia, they were unable to answer questions or provide any information regarding the allegations. Based on staff interviewed, staff changes residents 2-3x a day; before breakfast, in the afternoon after lunch and before bed. According to staff, if residents soiled their diapers/clothes, dropped something on their clothes or are maldorous, staff would immediately check on the resident and change them.

Based on the interviews conducted, the above allegation is 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, Maryanne Rodriguez and a copy is provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4