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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:33:13 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: 63DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Lack of supervision
Staff did not safeguard residents' belongings
INVESTIGATION FINDINGS:
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13
On 1/24/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. LPA toured the facility, interviewed staff, reviewed resident records, reviewed medication records and made observations during the course of the investigation.

Complaint alleges lack of supervision regarding staff sleeping while on duty. LPA was provided photos of what appears to be a caregiving staff sitting in a chair with their arms crossed. However, it is undetermined if staff's eye were closed or sleeping while on duty. Upon interviews with staff (S1, S3 & S4), LPA found that several staff have witnessed other caregiving staff to be sleeping while on duty during both afternoon and overnight shifts. Based on statements consistent with photo evidence pertaining to concerns, the allegations is found to be substantiated.

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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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 5
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: 01/24/2024
NARRATIVE
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Complaint alleges facility did not safeguard residents' belongings. Based on interviews with multiple staff (S1, S3 & S4) it was consistently indicated that residents clothing are often shared due to soiled clothing in need of cleaning. This ultimately resulted in the facility being unable to properly maintain and safeguard resident belongings, therefore the allegation is found to be substantiated.

Allegations, lack of supervision and staff did not safeguard residents' belongings 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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
General food requirements not met
Staff did not ensure that residents were appropriately dressed for hot weather
Staff did not seek a resident medical attention
Personal Rights
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1/24/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. LPA toured the facility, interviewed staff, reviewed resident records, reviewed medication records and made observations during the course of the investigation.

Complaint alleges general food requirements not met for staff with restricted diets. Based on a tour of the facilty, resident record review and observations, LPA was unable to find corroborating evidence towards the allegation. Resident dietary restrictions where clearly posted on the kitchen bulletin with kitchen staff updating the the resident diets monthly. Facility was found to have an ample amount of healthy food options available for residents all while following resident dietary restrictions.

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: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 01/24/2024
NARRATIVE
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Complaint alleges staff did not ensure that residents were appropriately dressed for hot weather. Based on a tour of the facility and LPA observations, residents under care were found to have appropriate clothing on and appear to be comfortable. Based on interviews with staff (S1, S2, S3 & S4) there was no indication of residents being dressed inappropriately based on weather conditions and temperatures, therefore the allegation is unsubstantiated.

Complaint alleges staff did not seek a resident medical attention for resident with a resident (R2) who was observed by Reporting Party to have skin picking behaviors resulting in R2 bleeding. Based on a review of records, the facility has documented and is aware of R2 behavior, indicating changes of condition and clearly documenting progress notes for when R2 was observed to be bleeding from skin picking. In addition, staff are documented to have provided 1st aid and cleaning to tend to R2's scratches. Due to a lack of corroborating evidence the allegation is unsubstantiated.

Complaint alleges facility violated residents' personal rights regarding staff yelling or speaking inappropriately to residents in care. Based on interviews with staff (S1, S2, S3 & S4) and Reporting Party, there is not enough corroborating evidence supporting the allegation. Based on LPA observations and tours of the facility, there were no observed occurrences of this behavior from staff, therefore the allegation is unsubstantiated.

A finding that the complaint allegations, general food requirements not met, staff did not ensure that residents were appropriately dressed for hot weather, staff did not seek a resident medical attention & facility violated resident personal rights are unsubstantiated meaning that although the allegation 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 allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
87411(a)
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87411 (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This was not met as evidence by:
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Facility agrees to submit plan of action on how to ensure staffing is sufficient and providing adequate supervision for residents in care. Plan of action to be submitted to CCLD by POC date 1/31/2024.
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Based on photo evidence and interviews with multiple staff, LPA found that caregiving staff have been witnessed to be asleep during their shifts which serves as a potential health & safety risk to residents in care.
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Type B
02/29/2024
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property and Valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables.. This was not met as evidence by:
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Facility agrees to submit plan of action on how to ensure resident personal clothing items are sufficient and maintained. Plan of action to be submitted to CCLD by POC date 1/31/2024. In addition, facility is to ensure all laundry machines pending repair or replacement have been resolved.
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Based on interviews with multiple staff, LPA received consistent information regarding resident clothing being shared amongst each other due to inaccessible clothing (soiled or requiring replacement). This serves as a potential personal rights risk to residents in care.
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Proof of Corrections Form LIC9098 confirming laundry machines for each cottage are functioning by POC due date 2/21/2024.
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: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5