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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 12/20/2023
Date Signed: 12/20/2023 05:42:43 PM

Substantiated


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
11/13/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20231113154439
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:NOEL FACTORFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 71DATE:
12/20/2023
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Rolinda Noquillo, Resident Service Director & Juliet McGranahan, Business Office DirectorTIME COMPLETED:
05:55 PM
ALLEGATION(S):
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Staff did not properly manage residents medications
Staff failed to keep facility clean, safe, and sanitary
Residents hygiene needs are not being met
INVESTIGATION FINDINGS:
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On 12/20/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by the Resident Service Director, Rolinda Noquillo. LPA toured the facility, interviewed staff and outside parties, reviewed outside agency medication reports and made observations.

Complaint alleges staff did not properly manage residents' medication. Based on LPA observations and medication audit report review and interview with Omnicare Pharmacy Nurse (N1) it was found that medical technician staff are not properly following protocol for medication management. N1 indicated that staff (S2) was observed directly administering medication to residents' tongue/mouth where resident's are to be self-administered. In addition, There were several medications were observed to be expired and not properly disposed. Lastly, staff were observed pre-pouring medications when protocols listed in medication rooms indicate requirement for live dispensing and prohibits pre-pouring.
Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
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-20231113154439
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: 12/20/2023
NARRATIVE
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Staff failed to keep facility clean, safe, and sanitary. Based on a tour of the facility, photo evidence and LPA observations, it was found that resident living areas are not properly cleaned or maintained. LPA observed urine on resident bedroom floor next to bed and commode. Urine was observed on multiple resident communal toilet seats uncleaned by staff (photos taken). In addition, LPA received photo evidence of feces on the floor of resident living areas and on resident toilet seats.

Complaint alleges residents hygiene needs are not being met. Based on interview with home health agency staff (H1) it was indicated that staff had left resident (R2) soiled on multiple occasions. In addition, LPA received photo of evidence of several instances where resident (R1) was left in urine soiled clothing while resident common areas.

Allegations, staff did not properly manage residents medications, staff failed to keep facility clean, safe, and sanitary & residents hygiene needs are not being met are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20231113154439
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2023
Section Cited
CCR
87465(a)(4)
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The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:**
Based on review of Omnicare Pharmacy medication audit conducted 12/20/2023 and interview with Omnicare Nurse (N1) it was found that staff (S2) was observed
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Licensee failed to ensure staff are completing medication protocol in compliance with Title 22 regulations. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.
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inappropriately administering medications directly into residents' mouths/tongue when staff are to only provide assistance with self-administering. This serves as an immediate health & safety risk to residents in care.
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In addition, Licensee is to conduct medication administration training for all medtech staff. Completed and signed training to be submitted to CCLD by POC date 1/4/2023.
Type B
12/20/2023
Section Cited
CCR
87465(i)
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Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
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License failed to ensure resident medication is properly maintained. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.
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This was not met as evidence by:** Based on Omnicare Pharmacy audit it was found that the facility staff have not properly processed or disposed of several expired medication. This serves as potential health & safety risk.
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In addition, Licensee is to submit a LIC9099 Proof of Corrections Form self-certifying that all expired or discontinued medications are disposed of in a proper manner. LIC9099 to be submitted to CCLD by POC date 1/4/2023.
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20231113154439
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87464(f)
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87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by:**
Based on interview with home health agency (H1) it was found that H1 had observed resident
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Licensee failed to ensure residents were provided proper basic services. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.
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R2 left in soiled continence care on multiple occasions. In addition, based on photo evidence, resident R1 was observed to be left in soiled clothing on multiple occasions. This serves as an immediate health & safety and personal rights risk to residents in care.
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Type B
01/04/2024
Section Cited
CCR
87393(a)
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87303(a)-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by:**
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Licensee failed to ensure facility was in a clean, safe and sanitary condition. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.
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Based on tour of the facility, LPA observation and photo evidence it was found that the facility was not in safe or sanitary condition. Urine was observed uncleaned on resident bedroom floors, bathrooms as well as photo evidence indicating feces in common areas. This serves as a potential health & safety risk to residents in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4