<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:48:01 PM

Substantiated


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
07/17/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240717162214
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: 55DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Resident Services Director, Mary Anne RodriguezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident was adequately hydrated.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 9, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

Regarding the allegation, staff did not ensure resident was adequately hydrated, according to the reporting party, on July 4th, 2024, Resident 1 (R1) was transported to Seton hospital and was admitted for dehydration and bladder infection.

Based on medical documentations reviewed, it was found that R1 had a diagnosis of UTI and dehydration when admitted to the hospital. R1 was treated with multiple doses of IV fluid and clinically improved. Facility was unable to provide LPA any care notes to show that R1 was being adequately hydrated.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

Report is reviewed with Resident Services Director, Maryanne Rodriguez and a copy is provided
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 5
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
07/17/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240717162214

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: 55DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Resident Services Director, Mary Anne RodriguezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident’s death.
Staff left resident soiled for an extended period.
Staff did not adequately address a change in resident’s condition.
Staff did not seek timely medical attention for a resident.
Staff did not assist resident with repositioning.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 9, 2025, Licensing Program Analyst (LPA) Komal Charitra conduc ted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Resident Services Director, Mary Anne Rodriguez and explained the purpose of the visit.

Regarding the allegation, staff neglect resulted in resident’s death, according to the reporting party, Resident 1 (R1) suffered negligence at this facility as R1 declined drastically in one month from the lack of care. In addition, according to the reporting party, on July 4, 2024, R1 was transported to the hospital and was admitted for dehydration and bladder infection. R1 worsened and required ICU admission for massive pulmonary embolism from immobilization and passed away on July 12, 2024.

During the investigation, the Department reviewed copies of R1’s medical record. Based on medical records reviewed, R1 was admitted to the hospital on 7/4/24 for UTI, dehydration and acute kidney injury. Based on the medical records, the cause of death was from cardiogenic shock due to Pulmonary embolism. The Department found no evidence that R1 passed away due to neglect.

Regarding the allegation staff left resident soiled for an extended period, according to the reporting party, R1 was observed with wet underpants.
(Continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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 5
Control Number 14-AS-20240717162214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/09/2025
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
During the visit, LPA observed residents, attempted to interview residents and interviewed staff. LPA attempted to interview five residents, however due to their dementia, they were unable to answer questions or provide any information regarding the allegation. Residents observed were in clean clothes, and did not have a urine odor. Based on staff interviewed, staff changes residents 2-3x a day; before breakfast, after lunch and before bed. Staff indicated that they may change residents less or more often depending on the resident's service plan. According to staff, if residents soiled their diapers/clothes, staff would immediately check on the resident and change them if required.

Regarding the allegation, staff did not adequately address a change in resident’s condition, according to the reporting party, R1 was admitted to the facility in May 2024 and was assessed as needing Level 2 care, however in June 2024, the facility reassessed R1 and indicated R1 is now Level 4 care.

During the investigation, LPA requested to review R1's file, however LPA did not observe any completed reappraisals, service plans, or pre-appraisal appraisal. According to the Administrator, he was not the administrator at the time of the incident. In addition, according to the Resident Services Director, she is unsure why the file is incomplete as she was not employed at the facility when R1 was admitted.

Regarding the allegation staff did not seek timely medical attention for a resident, according to the reporting party, R1 was found not responding to stimulus and was transported to the hospital.

During the investigation, LPA reviewed documents and interviewed staff. According to the Resident Services Director, on July 4, 2024 at around 12pm, R1 was walking towards his/her room with R1’s responsible party when R1 suddenly became unresponsive. Med-tech and Resident Services Director immediately came to assist R1 and check his/her vitals. 911 was called and paramedics came to the facility at 12:05pm and transported R1 to the hospital.

Regarding the allegation staff did not assist resident with repositioning, according to the reporting party, during multiple visits conducted, it was found that R1 was left unattended on a wheel chair and was not being repositioned by staff.

Continue to 9099C
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20240717162214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/09/2025
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
During the investigation, LPA reviewed R1's file and interviewed Resident Services Director. LPA was unable to find any completed reassessments and/ or service plans to indicate that R1 required repositioning. According to the Resident Services Director, R1 was able to walk with a walker but at times needed a wheelchair. Based on the physician's report dated 12/28/2023, R1 was listed as ambulatory. According to a staff member interviewed who was employed during the time R1 was at the facility, R1 did not need repositioning as he/she was able to walk with a walker. In addition, it was stated R1 required assistance getting up from bed and getting back down in bed.

Based on the interviews conducted and information collected, the above allegations are UNSUBSTANTIATED. Although the allegation 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 allegation is unsubstantiated at this time.

Report is reviewed with Resident Services Director, Maryanne Rodriguez and a copy is provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20240717162214
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall conduct in-service training regarding the importance of hydration and how to ensure residents are hydrated. Training shall include being able able to identify when a resident is dehydrated and intervening. In service training shall be submitted to CCL by 1/10/25
8
9
10
11
12
13
14
Based on medical records reviewed, the resident was found to have a diganosis of dehydration and UTI when admitted to the hospital which resulted in the resident needing multiple doses of IV fluids while at the hospital. This finding poses an immediate health a safety risk to the resident in care.
8
9
10
11
12
13
14
A civil penalty of $250.00 will be issued on 1/9/2025 for a repeat violation within the last 12 months. The same violation was cited on 11/6/2024
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5