486803645-11-8-2022-21-AS-KMOA-CL8UUE-20221116145323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 11/08/2022
Date Signed: 11/08/2022 11:45:57 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
04/01/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20220401095352

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: 53	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Executive Director, Jeff Gollihar		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff failed to meet resident's needs
Facility staff neglected in care resulting in resident hospitalization
Facility failed to assist with administration of medication as prescribed
Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue and deliver findings for a Complaint Investigation regarding the above allegations and met with Executive Director, Jeff Gollihar.

During the course of the Investigation, Licensing Program Analyst (LPA) Felias reviewed and requested documents, made observations at the facility, and conducted interviews.
There is an allegation that Facility failed to meet resident’s needs. Emails and photographs provided to LPA stated concerns that facility was not assisting Resident 1 (R1) with care needs such as putting on and taking off R1’s compression leg wraps and incontinence care. Review of Facility’s Electronic Medication Administration Record (MAR), Physician’s Report dated 04/19/2021, and Physician’s Orders dated 03/11/2022 for R1 show that facility administered daily leg wraps as ordered by R1’s Physician and documented when R1 would refuse to have them applied.
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: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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 4

Control Number 21-AS-20220401095352

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: 11/08/2022

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

Continued from LIC-9099

Interviews conducted also stated that R1 could be combative towards staff when being provided care. Interviews stated that facility protocol for incontinence care was to check on residents every two hours. Records reviewed showed that facility documented when R1 would refuse care. Records reviewed also showed that a Care Conference meeting between the facility and R1’s responsible parties dated 01/15/2022 addressed the noted concerns. Based on Interviews conducted, Review of Facility Documents, and Review of R1’s Physician’s Report, Physician’s Orders, and MAR, the LPA is unable to determine if the facility failed to meet resident’s needs, therefore this allegation is Unsubstantiated.

There is an allegation that Facility staff neglected in care resulting in resident hospitalization. Report dated 04/01/2022, stated that on 03/24/2022, R1 was found on the facility patio by family and was observed to be left out in the sun with no water or supervision. Review of R1’s Hospital Visitation Records for 03/24/2022 stated that per Emergency Personnel Services (EMS), R1 was unresponsive for approximately 10 minutes but was at their neurocognitive baseline by time of EMS transport. Upon arrival to hospital, R1 was found to have an initial diagnosis of hypothermia. A Review of R1’s Discharge Summary dated 3/31/2022 stated that the Hospital’s Principal diagnosis for R1 was Syncope. Attempts to retrieve Emergency Personnel Services (EMS)/Paramedic reports to review R1’s observed condition before and during transport to the hospital were unsuccessful. Staff interviews conducted stated that R1 was out in the sun for no longer than 10-15 minutes and was able to ambulate appropriately when asked. Interviews stated that R1 wanted to stay outside and became combative when facility staff tried to get R1 to come inside. Interviews also stated that facility would provide sun hats for residents and ensure they stayed in the shade when the sun was out. Staff would also remind residents to use the hydration stations available on the patio for water. During visits conducted on 4/20/2022 and 7/1/2022, LPA observed stations of water available for residents on the patio. Records reviewed stated that on 03/24/2022, R1 was still responsive while waiting for EMS to arrive and all R1’s vitals taken before transport were normal. Review of Facility Incident Report submitted to Community Care Licensing (CCL) dated 3/31/2022, indicated that the Incident occurred at 10:30AM on 03/24/2022. Per weather website, www.timeanddate.com, the temperature during the incident time was approximately 73 degrees F. Program Clinical Consultation Report dated 10/03/2022, was not able to come to a determination if R1’s diagnosis of Syncope was related to being outside on the patio.

Continued on LIC-9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220401095352

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: 11/08/2022

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

Continued from LIC-9099C

Due to conflicting information provided during Interviews conducted, Record Review, Review of Program Clinical Consultation Report, and Observations made, the LPA is unable to determine if the facility neglected in resident's care resulting in their hospitalization. Therefore, this allegation is Unsubstantiated.

There is an allegation that Facility failed to assist with administration of medication as prescribed. Photographs provided to LPA show that the medication(s) alleged to have been incorrectly administered was labelled as “Overflow.” Based on Interviews conducted, Overflow medications are described as medications that have been reordered and received by the facility but do not have to be opened until the medication currently in use is empty. Overflow medication are extra medicine that the facility keeps on hand in the event the current medication runs out in their medication cart. Review of Facility’s Electronic Medication Administration Record (MAR), Physician’s Report dated 04/19/2021, and Physician’s Orders dated 03/11/2022 for R1 show that facility administered medication as ordered by R1’s Physician and documented when R1 would refuse to take their medication. Based on Interviews conducted and Review of R1’s Physician’s Report, Physician’s Orders, and MAR, the LPA is unable to determine if the facility failed to assist with the administration of medication as prescribed, therefore this allegation is Unsubstantiated.

There is an allegation of Personal Rights. It is alleged that R1 was left sitting in urine, having urine-soaked clothes, and having multiple lesions. Review of Hospital Visitation Records dated 3/24/2022, stated that R1’s skin was observed to have no rashes, and was warm and dry. Records did not notate the condition of R1’s clothing when they arrived at the hospital and there was no documentation of R1 smelling of urine or observed to be in soaked clothing. Attempts to retrieve Emergency Personnel Services (EMS)/Paramedic reports to review R1’s observed condition before and during transport to the hospital were unsuccessful. Records reviewed do not show any documentation of skin breakdown in the days prior to R1's hospital visit.

It is alleged that on the following dates, 10/2021 and 1/14, R1 was observed to have a black eye with no explanation provided. Review of Resident Records indicated that on 10/04/2021 and 10/05/2021, facility was aware that R1 sustained a black eye but did not know how it occurred as there was no fall reported. Records reviewed did not indicate that R1 sustained a black eye on 1/14/2022. A Care Conference meeting between the facility and R1’s responsible parties dated 01/15/2022 did not mention the observation of a black eye although it was alleged to have occurred on 1/14/2022.

Continued on LIC-9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220401095352

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: 11/08/2022

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

Continued from LIC-9099C

Review of Facility Incident Reports to Community Care Licensing (CCL) indicated that these instances were not reported to the Department. Based on Record Review and Interviews conducted, the LPA is unable to determine if there was a Personal Rights violation, therefore this allegation is Unsubstantiated.

A finding that the complaint is Unsubstantiated means 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.

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: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4