486803645-10-5-2022-21-AS-HDBI-CKD2KB-20221019172739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:56:59 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
07/05/2022 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20220705125401

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: 55	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Jeffery Gollihar		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident needs not being met

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, Jeffery Gollihar, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA reviewed facility records, staff records and outside agency records. LPA conducted tours of the facility on July 12, 2022, July 21, 2022, August 11, 2022 and August 26, 2022.

Complaint alleges that Resident needs not being met. Based on interviews conducted, LPA could not prove or disprove that resident needs are not being met. In addition, during a collateral interview with an outside agency witness, LPA learned that the resident was observed to be clean based off of there observation on July 11, 2022. (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: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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-20220705125401

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: 10/05/2022

NARRATIVE

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Furthermore, LPA reviewed facility and resident records on August 1, 2022 and found no concerns during those reviews. LPA conducted a tour on July 12, 2022 during the opening of the complaint and observed no concerns with the physical plant of R1's room. In addition, LPA did not notice a smell of incontinence in the air.

A finding that the complaint allegation of Resident needs not being met are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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