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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 06/05/2023
Date Signed: 06/05/2023 11:20:19 AM


Document Has Been Signed on 06/05/2023 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:JEFFERY GOLLIHARFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 58DATE:
06/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Jeffery GolliharTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of following-up on incident reports that were forwarded to the Regional Office (RO). LPA was met by Administrator, Jeffery Gollihar, and was granted access into the facility.

CCL received an incident report on May 10, 2023 indicating a medication error. The error occurred on May 09, 2023 while Med Tech was dispensing medication. R1 was given the wrong prescribed medication during medication passing and was up all night. Administrator acknowledged the error and was educated on the importance of the facility dispensing the correct medication to residents in care. Responsible party and prescribing doctor were notified of medication error. LPA obtained a copy of the Medication Assessment Record (MAR) for the month of May 2023 (See LIC 809D).

CCL received an incident report indicating a fall that occurred on Mary 9, 2023 and an update occurring on May 16, 2023. The incident occurred while resident was going to use the restroom, but fell. Resident was subsequently hospitalized and then discharged to a Skilled Nursing Facility (SNF) for rehabilitation due to the fall. Appropriate parties were notified in a timely manner. Resident has discharged from the facility to the SNF for a long term period and is no longer residing at the facility. Deficiencies were not cited as proper Reporting Requirements and appropriate parties were notified in a timely manner.

CCL received an incident report and an SOC 341 on May 22, 2023. The incident occurred on May 17, 2023 when the Responsible Party/son came to pick up the resident, but the resident refused to get in the car. Responsible Party/son yanked him into the car, screaming and yelling. Facility's contingency plan was to review the Care Plan and update the Medication with the Primary Care Physician. All appropriate parties were notified. Currently, the resident is at a Skilled Nursing Facility (SNF) for rehabilitation purposes and for wound treatment. Resident has discharged from the facility to the SNF for a long term period and is no longer residing at the facility. Deficiencies were not cited as proper Reporting Requirements and other agency contacts were notified.

A Deficiency is cited for the Medication Error occurring on May 9, 2023 from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2023 11:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
CCR
87465(a)(5)

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87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.

This requirement is not met as evidenced by:
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Administrator agrees to submit proof of additional training for medication passes with ALL staff and to ensure future compliance and submit an LIC 9098-Self Certification.
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Based on record review and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
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Administrator shall provide a plan to train all staff by June 5, 2023. In addition, Administrator shall provide a sign-in sheet with proof of training by June 13, 2023.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
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