486803645-9-1-2022-21-AS-BMOS-CHZU4B-20220906151448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:30:25 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
06/08/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20220608122133

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: 58	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mae Mora		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident is being assaulted by other residents in care, causing injury.
Residents injured due to lack of staffing/supervision

INVESTIGATION FINDINGS:

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*****This report is an amended version of the original that was created on 07/06/2022. This LIC9099 supersedes the report generated on 07/06/2022*****
At approximately 9:45AM, Licensing Program Analyst's (LPA's) Caitlynn Felias and Chris Arnhold arrived at this facility to conduct an investigation into the above allegations. LPA's met with Resident Services Director Mae Mora, toured the facility, interviewed staff and reviewed records. Based on records reviewed and interviews conducted, the facility does have residents with aggressive behavior at times. Staff receive training upon being hired at the facility on how to intervene when a resident shows this behavior. LPA's received staff schedules that showed there was sufficient staff present during an incident between Resident 1, (R1) and two other residents. LPA's interviewed staff who were present during the incident. Staff told LPA's R1 refused to be redirected and inserted themselves between two other residents, which resulted in R1 being assaulted. Staff were able to redirect R1 at this point. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

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-20220608122133

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: 09/01/2022

NARRATIVE

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LPA's reviewed what basic services are provided at the facility. Facility staff provide assistance with activities of daily living but do not provide one on one care or continuous observation. A review of resident records did not reveal any prior incidents of aggression between R1 and these residents. LPA's reviewed pre-placement documentation and did not find any indication that any of the residents involved required 1 on 1 care. There was nothing in the records regarding aggressive acts in the past.
R1 was involved in another incident with a different resident where the resident did not allow R1 to leave a doorway. The other resident pushed R1, which caused R1 to receive a skin tear. LPA's reviewed staff schedules and observed there were a sufficient number of staff on duty that day. Residents are free to walk through the facility grounds. When staff observe residents begin to have an altercation, they immediately attempt to intervene. When the situation calls for more support, local law enforcement is contacted.

Facility made all appropriate notifications per regulation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

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