486803645-2-6-2023-21-AS-KMOA-CNUVAT-20230208151629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 02/06/2023
Date Signed: 02/06/2023 10:11:42 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
01/18/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230118134951

FACILITY NAME:	PACIFICA SENIOR LIVING VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	JEFFERY GOLLIHAR		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 59	DATE:	02/06/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Jeffery Gollihar		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility is not reporting
Staff did not observe resident for changes
Staff are not following the resident's care plan
Staff spoke to resident inappropriately
Facility neglect resulted in resident's unexplained injuries
Facility is financially abusing resident.

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 reviewed resident records, staff records, outside agency report, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses. LPA toured the facility on January 13, 2023 and observed remodeling occurring at the facility which was not reported to Community Care Licensing (See LIC 9102-Technical Advisory). LPA educated Administrator regarding the importance of notifying Community Care Licensing when an alteration is occurring.

(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: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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-20230118134951

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: 02/06/2023

NARRATIVE

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Complaint alleges that staff are not observing resident for changes and facility is not reporting. Based off interviews that were conducted with additional residents and staff, LPA could not prove or disprove that staff are not observing resident for changes and that the facility was not reporting. Furthermore, statements made during the investigation could not corroborate the allegation. LPA reviewed resident records and learned that Resident #1 did not have a change of condition and thus facility had no need to report no changes of condition to Community Care Licensing.

Complaint alleges that staff are not following the resident's care plan and facility is financially abusing resident. LPA reviewed resident records which included the Care Plan, interviewed staff and Resident #1. LPA learned that Resident #1 required a two person assist. Based off interviews that were conducted and a review of resident records, LPA could not prove or disprove that staff are not following resident’s care plan and that the facility is financially abusing the resident due to inconsistent statements made to the LPA during the course of the investigation.

Complaint alleges that staff spoke to resident inappropriately and facility neglect resulted in resident's unexplained injuries. Based off interviews that were conducted with additional residents and staff, LPA could not prove or disprove that staff spoke to resident inappropriately. In addition, LPA reviewed an outside agency report and interviewed additional witnesses. Furthermore, statements made during the investigation and the review of the outside agency report could not corroborate the allegation due to inconsistence statements made during the course of the investigation.

A finding that the complaint allegations of facility not reporting, staff did not observe resident for changes, staff are not following the resident's care plan, staff spoke to resident inappropriately, facility neglect resulted in resident's unexplained injuries, facility is financially abusing resident 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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC9099 (FAS) - (06/04)

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