415601046-4-12-2023-14-AS-KHOS-CRFJA6-20230502065214

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:18:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/05/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230405162141

FACILITY NAME:	PACIFICA SENIOR LIVING MISSION VILLA		FACILITY NUMBER:	415601046
ADMINISTRATOR:	NICKOLAI, KAREN		FACILITY TYPE:	740
ADDRESS:	995 E MARKET ST		TELEPHONE:	(650) 756-1995
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	60	CENSUS:	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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- Facility failed to ensure infection control practices were followed or maintained resulting in multiple residents getting scabies

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to investigate the allegation received. LPA met with the administrator and explained the purpose of today's visit.

During today's visit LPA discussed the allegations and reviewed the number of possible residents with scabies as well as reviewed the facility's infection control policies. According to the reviewed items the facility is adhering to their policies at this time and scabies is not found to be wide spread through out the facility inidcating control practices are being followed. According to the administrator the facility has been reporting to public health regulalry and residents affected will have met the isolation and medication periods. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations 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 allegations are unsubstantiated at this time. Report is reveiwed with the administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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