486803645-8-11-2022-21-AS-HDBI-CHK2KU-20220822172832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:44:29 AM

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
07/19/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220719124147

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:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Administrator, Melody Lee Allmond		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility has mold
Facility not maintained in good repair
Staff do not provide resident with bed linen

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Melody Lee Allmond, and was granted access into the facility.

Complaint alleges that the Facility has mold and facility is not maintained in good repair. During the course of the investigation, LPA toured the facility and made observations on August 11, 2022 and July 21, 2022. During those tours, LPA found the facility to be clean, sanitary and in good repair. In addition, during the tour on July 21, 2022, LPAs Farhaan Sarangi and Caitlynn Felias observed no mold in any of the alleged areas of concern. Based off of observations and the interview with the maintenance director, LPA could not prove or disprove that the facility has mold and is not maintained in good repair.

(Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20220719124147

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: 08/11/2022

NARRATIVE

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Complaint alleges that staff do not provide resident with bed linen. During the course of the investigation, LPA toured the facility and made observations on August 11, 2022 and July 21, 2022. During those respective tours, LPA found the facility to be clean, sanitary and in good repair. In addition, on said dates, LPA observed residents to have sufficient bed linens on beds that residents reside on. Based off of observations, LPA could not prove or disprove that the residents are without bed linens.

A finding that the complaint allegations of, Facility has mold, facility is not maintained in good repair and staff do not provide resident with bed linen are unsubstantiated meaning that 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 allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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