415601046-5-12-2023-14-AS-KHOS-CSQHW3-20230612063252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:29:01 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
10/06/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221006165203

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: 57	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not prevent a skin rash outbreak at the facility
Staff lock residents in room from an extended period of time
Staff are not meeting resident's bathroom needs resulting in residents left in soiled clothing
Staff are not scheduling medical check ups for residents in care
Staff are not meeting resident's hyigene needs
Staff are not providing a safe and healthy environment to residents in care

INVESTIGATION FINDINGS:

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

During the course of the investigation LPA conducted interviews with staff and made facility observations. LPA could not reach a preponderance of evidence standard to substantiate any of the allegations received as conflicting information, and one party's word over another, could not aid in the determination of any of the allegations. LPA was unable to confirm the merit of the received alletgations as LPA could not speak to the reporting party. These allegations are 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 executive director Karen Nickolai.

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: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

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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