415601046-4-12-2023-14-AS-KHOS-CRLNG4-20230507102631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:20:03 PM

Unfounded

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
08/18/2021 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210818145838

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: 59	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff did not conduct a preadmission appraisal for resident prior to move-in
- Illegal eviction
- Facility did not provide resident a refund in compliance with the admission agreement

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the above allegations. LPA met with the administrator Karen Nickolai and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews and reviewed pertinent documents received regarding the allegations and the resident involved. LPA discovered that the facility did provide a refund to the responsible party. Illegal eviction did not occur as the facilty did not evict the resident at anytime. Lastly, there was an appraisal conducted prior to move-in of the resident that is on record.

This agency has investigated the complaint alleging Staff did not conduct a preadmission appraisal for resident prior to move-in, Illegal eviction, and facility did not provide resident a refund in compliance with the admission agreement. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with the administrator Karen Nickolai.

Unfounded

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)

Page: 1 of 3

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
08/18/2021 and conducted by Evaluator Jaime Vado

COMPLAINT CONTROL NUMBER: 14-AS-20210818145838

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: 59	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff mismanaged resident's medications
- Resident's authorized representative not informed of change in condition
- Staff providing false facility advertisement
- Staff did not intervene in a timely manner to an altercation between residents
- Staff isolated resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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)

Page: 2 of 3

Control Number 14-AS-20210818145838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA	FACILITY NUMBER: 415601046
	VISIT DATE: 04/12/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2 - LIC9099

Regarding the allegation of not informing responsible party of change in condition of resident, LPA observed incident reports and some email notifications of such changes to the responsible party.

Regarding the allegation of false facility advertisement, LPA reviewed the items presented as false reviews and in interviewed facility staff regarding this. LPA could not prove fault by the facility as it is one party's work versus another.

Regarding the allegation of staff not intervening in a timely manner between two residents, LPA reviewed incident reports and staff regarding the incident. LPA could not prove that the staff did not intervene in a timely manner. In reviewing items the staff did intervene to the best of their abilities and was able to observe, intervene, and report such incidents. The facility does not have one on one caregivers for R1 as it is not in the admission agreement or needs or services plan.

Lastly, regarding the allegation of staff isolating the resident LPA could not determine if this took place or not. According to interviews conducted there are conflicting views regarding the isolation as described. The room in question the resident was not locked in. No resident rooms have locks on them. LPA could not prove or disprove that this took place as it is one party's work over the other.

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 reviewed with the administrator Karen Nickolai.

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3