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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:23:25 PM


Document Has Been Signed on 04/26/2024 04:23 PM - 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:NOEL FACTORFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 67DATE:
04/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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On 4/26/2024, LPA's Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan. On 1/6/2024, resident (R1) had sustained lacerations to their shoulder and arm after an unwitnessed fall located in the facility courtyard during evening hours. During the complaint investigation, LPA's found that although it was undetermined whether resident R1 had sustained a severe injury, the facility still failed to ensure R1 was provided adequate supervision resulting in R1 injured and found outside of their designated living quarters in facility courtyard. LPA's issued citation under Health & Safety Code "Enumerated Rights; Severability" 1569.269.

Deficiency cited from the California Health & Safety Code, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Civil Penalty issued for a total of $250 for repeat violation.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/26/2024 04:23 PM - 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: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2024
Section Cited
HSC
1569.269

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Enumerated rights; severability(a(6) - ..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**
Based on interviews with Administrator and
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Facility failed to ensure that proper care and supervision were provided to resident R1. Administrator agrees to submit updated plan of action on how staff are to provide adequate supervision for all residents during evening hours. Written statement to be submitted to CCLD by POC date 4/28/2024.
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a review of resident R1 medical and facility records, it was found that facility failed to ensure proper supervision resulting in R1 left unsupervised, causing unwitnessed fall and injury in the facility courtyard. This serves as an immediate health & safety risk to residents in care.
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Civil Penalty issued for a total of $250 for repeat violation.

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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: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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