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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:37:39 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
08/19/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20220819095323
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: 52DATE:
12/09/2022
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Jeff Gollihar, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 12/9/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced visit for the purpose of delivering complaint findings and was greeted by Executive Director, Jeff Gollihar. LPA Tobola toured the facility, conducted interviews with staff, reviewed files and made observations during the investigation.

Complaint alleges the facility violated resident's (R1) personal rights. Based on a tour of the facility, observations LPA did not witness any residents being inappropriately treated both physically and verbally by staff. In addition, based on several interviews with staff (S1,S2,S3,S4,S5 & S6), LPA received conflicting information with no witnesses to the incident claiming resident R1 had been hit by staff (S1).

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
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 2
Control Number 21-AS-20220819095323
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: 12/09/2022
NARRATIVE
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 LPA conducted an interview with alleged witness staff (S2) who confirmed that they did not witness staff (S1) hit R1 or any other resident while providing care. S2 stated that during an incident in July 2022, resident R1 was a new admission to the facility and had previously demonstrated physically aggressive behaviors on several occasions. During the incident S2 claimed that resident R1 had attempted to hit S2, staff S1 and other residents. S2 informed LPA that staff S1 was observed to have blocked R1 from physically hitting other residents and staff in the house.

Based on a tour of the facility, interviews, record review and observations during the investigation, the allegation that resident R1's personal rights were violated are found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited during today's visit. Appeal Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2