486803645-7-6-2022-21-AS-BMOS-CHZU4C-20220906151448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:05:12 PM

Substantiated

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: 59	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Mae Mora		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff not trained to address serious behaviors resulting in residents being injured

INVESTIGATION FINDINGS:

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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, staff records do not contain evidence of required annual training for dementia specific training. LPA's reviewed staff training documentation and found the documented training did not meet the requirements of regulation.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Mae Mora and Appeal rights were given.

Substantiated

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: 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)

Page: 1 of 3

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: 59	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Mae Mora		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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5
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9

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. A new LIC9099 was created to add additional information. The new LIC9099 supersedes this report*****
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 intervien when a resident shows this behavior. Basic services at the facility provide assistance with activities of daily living but do not provide one on one care or continuous observation. Residents are free to walk through the facility grounds. When staff observe residents begin to have an altercation, they immediately attempt to intervien. 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.

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)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/29/2022 Section Cited CCR 87707(a)(2)	1 2 3 4 5 6 7	Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia...and in each succeeding 12-month period. This requirement is not met as	1 2 3 4 5 6 7	Licensee to ensure staff assisting resident with dementia receive on-going annual training specifically addressing care needs of residents with dementia. Licensee to review regulation requirements and submit
	8 9 10 11 12 13 14	evidenced by: Based on records reviewed, Licensee did not have at least 8 hours of documented in-service training for staff. This poses a potential Health, Safety or personal rights risk to residents.	8 9 10 11 12 13 14	plan to CCL to ensure staff receive required training per regulation.
	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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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