486803645-1-24-2024-21-AS-VBEI-D2HVQD-20240216153812

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:35:42 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
11/20/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20231120113822

FACILITY NAME:	PACIFICA SENIOR LIVING VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	NOEL FACTOR		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 63	DATE:	01/24/2024
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Juliet McGranahan, Acting Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Neglect/Lack of supervision of resident's incontinence care resulting in pressure injury

INVESTIGATION FINDINGS:

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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 Tobola toured the facility, interviewed staff and outside parties, reviewed resident records and made observations during the course of the investigation.

Complaint alleges neglect/Lack of supervision of resident's incontinence care resulting in pressure injury. Based on a review of resident (R1) records, LPA found that R1 had a history of skin breakdown and entered the facility with wounds on R1's heel and groin area as noted on R1's assessment for admission. R1 was found to be admitted on 10/13/2023. Upon review of R1's progress notes it was indicated that on 11/11/2023, staff observed a wound on R1's coccyx area. The wound in this area was not present prior to R1's admission.

Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (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)

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Control Number 21-AS-20231120113822

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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Based on interviews with Reporting Party, and multiple outside parties (I2, I3 & I4) LPA found statements to be consistent with observations regarding resident R1 being left in soiled continence care products. In addition, (I4) indicated concerns of R1 being left in bed a majority of the time while in the facility, with staff not properly equipped to use hoyer lift for R1's mobility and repositioning. I4 also stated having observed a lack of repositioning, encouraging mobility and continence care not properly provided, resulting in R1 developing additional pressure sore while under the facility's care.

Allegation, neglect/lack of supervision of resident's incontinence care resulting in pressure injury is 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.

This is an amendment of the original report to indicate civil penalty language and amount correction**

LPA issued Civil Penalty at a total amount of $250 for repeat violation within a 12 month period for regulation 1569.625(b)(2).

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (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)

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Control Number 21-AS-20231120113822

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 A 02/25/2024 Section Cited HSC 1569.269	1 2 3 4 5 6 7	Enumerated rights; severability-To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not met as evidence by:	1 2 3 4 5 6 7	Facility failed to ensure staff were sufficient and competent to provide necessary services to meet resident needs. Administrator is to implement a vendorized training for all staff that provide resident care on continuous bedridden care, continence care and other topics pertaining to
	8 9 10 11 12 13 14	Based on observation, records review & interviews, the licensee did not comply with the section cited above involving resident R1's needs not being met resulting in development of pressure sore while under facility care which poses an immediate health & safety risk to persons in care.	8 9 10 11 12 13 14	meeting resident physical care requirements. Training date is to be submitted to CCLD by POC date 1/25/2024. Completed training log signed by all staff is to be submitted to CCLD by POC date 2/8/2024. This is an amendment of the original report to indicate civil penalty language and amount correction** Civil penalty of $250 issued for repeat violation within a 12 month period for regulation 1569.625(b)(2).
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (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)

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