486803645-7-6-2022-21-AS-KMOA-CHMMD2-20220825093023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:19:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20220413151900

FACILITY NAME:	PACIFICA SENIOR LIVING VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	LEE-ALLMOND, MELODY		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 59	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Resident Services Director, Solomae (Mae) Mora		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff are not assisting residents with managed incontinence.
Facility is in disrepair and not clean and sanitary.
Staff are leaving residents out in the sun.
Staff are not following physicians orders.
Staff do not obtain medical care for resident.

INVESTIGATION FINDINGS:

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At approximately 10:45AM, Licensing Program Analysts (LPAs) Felias and Arnhold arrived unannounced to continue a Complaint investigation regarding the above complaint allegations.
There is an allegation that staff are not assisting residents with managed incontinence. Although some residents are documented to be difficult during incontinence changing, based on File Review and Staff Interviews, residents are being assisted with managed incontinence as needed. The allegation that staff are not assisting residents with managed incontinence is UNSUBSTANTIATED.
There is an allegation that Facility is in disrepair and not clean and/or sanitary. Throughout the course of this investigation, LPAs toured and observed each living area of the facility and found the facility to be clean and in good repair. LPAs observed a pet in one of the living units. The litter box was clean and did not have an odor. LPAs observed resident bedding. Bedding was observed to be clean and free of foul odors. Review of Facility Documents indicated that bedding for residents is changed often. The allegation that Facility is in disrepair and not clean and/or sanitary is UNSUBSTANTIATED.
Continued on LIC-9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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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Control Number 21-AS-20220413151900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE	FACILITY NUMBER: 486803645
	VISIT DATE: 07/06/2022

NARRATIVE

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Continued from LIC-9099
There is an allegation that Staff are leaving residents out in the sun. Based on LPAs observations and a review of the Program Design, residents are able to sit outside on the community patio. Patio has multiple areas that provide shade and cover for residents including trees and seating areas with umbrellas. During the course of this investigation, LPAs also observed staff members checking on residents if they were sitting outside. Based on interviews conducted, residents are provided sun hats and are also reminded to drink water from the water stations available in each house and on the patio. Review of Facility Documents did not show evidence of residents’ sustaining sun burns. The allegation that Staff are leaving residents out in the sun is UNSUBSTANTIATED.

There is an allegation that Staff are not following physician’s orders. Based on Staff Interviews conducted, for residents to have something applied like sunblock or suntan lotion, a physician’s order would be needed. Of the resident files reviewed, none showed to have a physician order for sunblock or suntan lotion. Based on Staff Interviews and File Review conducted, diabetic residents are offered sugar-free options. If residents’ sugars are shown to be low, staff provide snacks or juice to help raise residents’ sugar. Medication Record review shows that insulin is administered as ordered. The allegation that Staff are not following physician’s orders is UNSUBSTANTIATED.

There is an allegation that Staff do not obtain medical care for resident. Based on Facility Documents and File Review conducted, facility notified Responsible Parties, Physician, Emergency Personnel, and monitored resident appropriately. The allegation that Staff do not obtain medical care for resident is UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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