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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 05/26/2021
Date Signed: 05/26/2021 02:54:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2021 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20210127091809
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mae Mora, Resident Service Director TIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to ensure a safe and sanitary environment
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/26/2021 Licensing Program Analyst (LPA) Tobola delivered complaint findings regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director, Mae Mora by tele-visit. Facility was toured, facility resident and medical records were reviewed and interviews with staff and other outside parties were conducted.

Complaint alleges that staff failed to ensure a safe and sanitary environment. Upon review of resident R1's records LPA learned that R1 required continence care and is to be kept clean at all times. Based on interviews with staff and outside parties as well as photos evidence it was found that resident R1's clothing had been soiled in urine. In addition, photos also show feces observed on the floor of R1's bedroom, therefore the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Continued onto LIC9099-C
Signatures on file
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2021 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20210127091809

FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 60DATE:
05/26/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mae Mora, Resident Service DirectorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not safeguard a resident's personal property
Facility failed to appropriately report resident condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/25/2021 Licensing Program Analyst (LPA) Tobola delivered complaint findings regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director, Mae Mora by tele-visit. Facility was toured, facility resident and medical records were reviewed and interviews with staff and other outside parties were conducted.

Complaint alleges facility staff did not safeguard resident's personal property. Based on review of resident R1's records there was no indication that R1 required the use of a bedside commode or personal alarm system. Based on facility tour LPA found that all resident rooms include a motion sensor that is turned on when the resident is in the room. Additionally, based on interviews with staff and outside parties LPA received contradicting information related to the allegation and is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Continued onto LIC9099-C
Signatures on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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 21-AS-20210127091809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
VISIT DATE: 05/26/2021
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
Complaint alleges facility failed to appropriately report resident condition to R1's Physician. Based on staff interviews and a review of resident records LPA found that the facility recorded chart notes for R1 whenever there was a change of condition. R1's chart notes also indicated that the facility notified R1's family and Physician. LPA however was unable to find any corroborating evidence that the facility was consistent with the information provided to R1's Physician compared to R1's chart notes meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. Appeal Rights given. Signatures on file.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20210127091809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
VISIT DATE: 05/26/2021
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
Complaint alleges that residents' personal rights were violated due to staff not wearing face coverings while providing care for residents. Based on interviews with the Administrator, staff and outside parties it was found that two staff S1 & S2 were observed providing care for residents without the use of face coverings based on facility COVID mitigation plan and protocols, therefore the allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Appeal Rights Given. Signatures on file
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20210127091809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2021
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in all Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:***
1
2
3
4
5
6
7
Administrator failed to protect the personal rights of residents in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care. Administrator has conducted a vendored in person training for staff in PPE Training on 1/4/2021 & PPE Donning and Doffing on 1/21/2021.
8
9
10
11
12
13
14
Based on interviews with staff, Administrator and outside parties LPA found that staff S1 & S2 failed to wear face coverings while providing care and supervision to residents in care*, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.
8
9
10
11
12
13
14
Copy of training records were provided to LPA. POC cleared during the time of visit.
Type B
06/09/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by:***
1
2
3
4
5
6
7
Administrator failed to ensure the facility is kept clean, safe, sanitary and in good repair at all times. Administrator agrees to review regulation 87303 and submit self-certification LIC9098 to CCL by POC due date 6/9/2021.In addition, Administrator agrees to conduct an in-service training for all staff for Resident Care and Cleanliness.
8
9
10
11
12
13
14
Based on interviews with staff, outside parties and photo evidence LPA found that R1's clothing had been be soiled in urine. In addition, feces were also observed on the floor of R1's bedroom.
8
9
10
11
12
13
14
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5