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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 05/10/2024
Date Signed: 05/10/2024 03:48:29 PM


Document Has Been Signed on 05/10/2024 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 57DATE:
05/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Manager - Jovy CastroTIME COMPLETED:
03:50 PM
NARRATIVE
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On 05/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to make observations regarding facility operations and staffing. LPA met with business office manager Jovy Castro and explained the purpose of today's visit. At this time there is no administrator assigned that sits in the facility providing oversight.

This is a two level facility. During today's visit LPA obtained the current staff schedule for this week and next week May 5 through May 11, and May 12 through May 18, and a facility resident roster. The facility is cleared to have 10 hospice residents and there are currently 8 on record under hospice. LPA toured the facility independently and conducted interviews at random. LPA observed dining room staff assisting resident and family members with a meal. LPA observed activities taking place on the ground floor. Per LPAs observations and review of staffing schedule there is only one med-tech on this day assisting residents with medications and care for both floors of the facility when usually there should be one med-tech on each floor. LPA observed 2 caregivers on the schedule on each floor in place. That is 2 caregivers on each floor totalling 4 caregivers for 57 residents in care. PM shift it identifies the addition of one staff member totalling 5 caregivers, if no one calls out, to 57 residents but still 1 med-tech handling medications for both floors which is the same med-tech from the AM shift. LPA conducted interviews at random and discovered a shortage of med-techs at this time resulting in the newly hired memory care director to hand out medications without having earned a med-tech certificate. This staff person is not fully trained at the time of today's visit and has handed out medications prior to the visit for several days. Per additional review and interviews it is discovered that additional med-tech and staffing into the weekend there is only 1 med-tech for AM and PM shifts, 3 caregivers for AM shift and 3 caregivers for PM shift for 57 residents in care for the entire facility.

Per LPA observations made on this day and documents reviewed there are staffing and training violations taking place. These violations pose a health and safety risk to residents in care. Citations are being issued on this day on the following LIC809-D.

Report is reviewed with business office manager Jovy Castro. A copy of this report is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2024 03:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This regulation has not been met as evidenced by:
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The licensee shall provide a plan in writing to address and indicate how they well meet this regulation at all times. POC to be received by the date indcated.
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Based on observations made and interviews conducted, there currently is only one med-tech handling AM and PM medications as well as 4 caregivers assiting residents at LPAs arrival. Per interviews and staffing schedule observed there is also only 1 med-tech for AM and PM for the next day, and 3 caregivers for AM and PM shfit for 57 residents. This violation poses a health and safety risk to residents in care.
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Type A
05/11/2024
Section Cited
HSC1569.69(a)(1)

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ยง1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This regulation has not been met as evidenced by:
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The licensee shall provide a plan in writing to address and indicate how they well meet this regulation at all times. POC to be received by the date indcated.
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Based on file review, the memory care director's file showed that she is not fully trained at this time and has passed out medications to residents as a reulst of the facility not having enough med-tech's on duty or on the schedule. This violation poses a health and safety risk to residents in care.
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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) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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