<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 10/21/2022
Date Signed: 10/21/2022 09:41:41 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-20220719101826
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 55DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Jeffery GolliharTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist resident with incontinence needs
Staff do not prevent resident from falling out of bed
Staff do not provide a safe and healthful environment by over medicating resident
Staff do not provide a safe and healthful environment by yelling at resident and visitor
Staff do not assist resident with hygiene needs
Staff do not assist resident with meal needs
Staff do not assist resident with wheelchair transfer
Staff do not safeguard resident's property
Staff in violation of admission agreement for resident activities
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 conducted tours of the facility on July 21, 2022 and August 11, 2022.

Complaint alleges that staff do not assist resident with incontinence needs and Staff do not assist resident with hygiene needs. Based on interviews that were conducted, LPA could not prove or disprove that the staff do not assist resident with incontinence need due to inconsistent statements made during the course of the investigation. LPA toured the facility during the opening of the complaint on July 21, 2022 and on August 11, 2022, LPA observed R1 and the dwelling space and found no concerns at the time of the inspections on said dates. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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
Control Number 21-AS-20220719101826
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: 10/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Complaint alleges that staff do not prevent resident from falling out of bed. Based on interviews that were conducted, LPA could not prove or disprove that the staff do not prevent the resident from falling out of bed. Furthermore, inconsistent statements were made during the course of the investigation. In addition, LPA reviewed facility documents that could not corroborate the allegation. However, during the course of the investigation and facility records review, LPA learned that there was only one LIC 602/Physician’s assessment that was made during R1’s residency at the facility from March 2022 through August 2022. (See LIC 809- Case Management-Deficiencies dated for October 21, 2022)

Complaint alleges Staff do not provide a safe and healthful environment by over medicating resident. During the course of the investigation, LPA reviewed the Medication Assessment Record dated for June 2022. LPA learned that there was a medication change on June 15, 2022 by the Nurse Practitioner that changed the medication dosage for R1. However, during this medication change, the pharmacy did not get the order in time and thus a missed medication was documented on the Medication Assessment Record for June 15, 2022. Based on interviews that were conducted, LPA could not prove or disprove the allegation.

Complaint alleges that Staff do not provide a safe and healthful environment by yelling at resident and visitor. During the course of the investigation, LPA reviewed facility documents including facility notes and facility sign-in sheets. Furthermore, LPA could not corroborate the allegation. In addition, based on interviews that were conducted, LPA could not prove or disprove that the staff do not provide a safe and healthful environment by yelling at resident and visitor.

Complaint alleges that Staff do not assist resident with meal needs. LPA reviewed facility documents and conducted interviews. LPA could not prove or disprove that the staff do not assist resident with meal needs. Based on interviews that were conducted, meals and food service were not a concern during R1’s residency at the facility.

Complaint alleges that Staff do not safeguard resident's property. LPA reviewed facility documents and facility notes and could not corroborate the allegation. Based on interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, during these interviews, dates and times of the property that was allegedly not safeguarded was unknown. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20220719101826
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: 10/21/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Complaint alleges Staff do not assist resident with wheelchair transfer and Staff in violation of admission agreement for resident activities. During the course of the investigation, LPA reviewed facility documents and conducted interviews and could not corroborate the allegation. Based on interviews that were conducted, LPA could not prove or disprove the allegation.

A finding that the complaint allegations of Staff do not assist resident with incontinence needs, Staff do not prevent resident from falling out of bed, Staff do not provide a safe and healthful environment by over medicating resident, Staff do not provide a safe and healthful environment by yelling at resident and visitor, Staff do not assist resident with hygiene needs, Staff do not assist resident with meal needs, Staff do not assist resident with wheelchair transfer, Staff do not safeguard resident's property, Staff in violation of admission agreement for resident activities 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 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 DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3