486803645-7-6-2022-21-AS-KMOA-CJAPPU-20220915113007

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:20:07 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
05/23/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20220523152030

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:	11:45 AM
MET WITH:	Resident Services Director, Solomae (Mae) Mora		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff left residents unattended for period of time.
Facility staff left resident soiled in urine and feces.
Staff made inappropriate comments in front of residents.
Staff did not keep facility free from pests.

INVESTIGATION FINDINGS:

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At approximately 11:45AM, 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 left residents unattended for period of time. Based on Staff Interviews conducted, Facility protocol is to have the Medication Technician on duty stay and attend to the residents until late staff arrive. There is always at least one staff member present. Review of Employee Time Cards show that two caregiving staff were approximately 15 minutes late for their shift but Medication Technician Time Cards corroborate with interviews conducted stating that the Medication Technician will stay to cover until staff arrive. The allegation that Staff left residents unattended for period of time is UNSUBSTANTIATED.
There is an allegation that Facility staff left resident soiled in urine and feces. 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.

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-20220523152030

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
Resident rooms were clean, commode in rooms were clean, and LPAs did not observe an odor of feces or urine. Residents appeared to be clean and well groomed. The allegation that Facility staff left resident soiled in urine and feces is UNSUBSTANTIATED.

There is an allegation that Staff made inappropriate comments in front of residents. Based on Staff Interviews conducted, LPAs could not find any supporting evidence or witnesses that heard staff make inappropriate comments towards residents. The allegation that Staff made inappropriate comments in front of residents is UNSUBSTANTIATED.

There is an allegation that Staff did not keep facility free from pests. Based on Facility Documents reviewed, facility has a contract and proof of invoices with an Exterminator. The Exterminator comes out monthly to put out pest traps and other deterrents. The allegation that Staff did not keep facility free from pests 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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