415601046-12-12-2023-14-AS-KHOS-D26JYE-20240205062746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 12/12/2023
Date Signed: 12/12/2023 01:06:40 PM

Unsubstantiated

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
05/03/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230503083207

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: 54	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Karen Nickolai		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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- Staff do not provide resident with housekeeping service
- Staff do not safeguard resident's personal belongings
- Staff do not assist resident with grooming
- Staff do not assist resident with showering
- Staff do not provide resident with toiletry item

INVESTIGATION FINDINGS:

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

During the course of the investigation LPA conducted interviews, reviewed documents, and made observations of the resident and their room. Resident appeared well kept, groomed, and their room is observed as in order. Toiletry items are provided based on resident evaluations and behaviors. Based on the investigation LPA could not prove or disprove if the allegations took place. 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 reviewed with Karen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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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