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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:17:50 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
01/22/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240122094705
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
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Reporting requirements not met
INVESTIGATION FINDINGS:
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On 4/26/2024, Licensing Program Analysts (LPA's) Tobola and Mutilau arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan (AD). LPA toured the facility, interviewed staff and outside parties, reviewed resident facility and medical records and made observations during the course of the investigation.

Complaint alleges reporting requirements not met. Upon a review of incident reports submitted to Community Care Licensing (CCLD), the facility failed to properly submit incident report involving resident (R1) sustaining a fall in the facility courtyard during overnight hours. LPA and AD found that the facility did not properly complete and submit a Special Incident Report LIC624 to CCLD or reporting parties for the incident involving R1 on 1/6/2024. Allegation, facility failed to follow reporting requirements 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. Appeal Rights Given
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
01/22/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240122094705

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
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Juliet McGranahan, Acting AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Complaint alleges staff did not seek resident timely medical attention
Neglect/Lack of Supervision resulted in resident sustaining a severe injury
INVESTIGATION FINDINGS:
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On 4/26/2024, Licensing Program Analysts (LPA's) Tobola and Mutilau arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Acting Administrator, Juliet McGranahan (AD). LPA toured the facility, interviewed staff and outside parties, reviewed resident facility and medical records and made observations during the course of the investigation.

Complaint alleges staff did not seek resident timely medical attention. Based upon a review of R1's medical records, it was determined that R1 had sustained an injury on 1/6/2024 due to an unwitnessed fall in the facility courtyard and confirmed that R1 received medical attention. Upon a review of R1's facility records, the facility completed an internal incident report also confirming that R1 had been sent out to the hospital for medical attention. Upon review of a second incident involving R1 sustaining injuries due to an unwitnessed fall also confirms that R1 had been assesed by appropriate hospice agency.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240122094705
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: 04/26/2024
NARRATIVE
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Complaint alleges, Neglect/Lack of Supervision resulted in resident sustaining a severe injury. Based on upon review of R1's medical and facility records it was found that on 1/6/2024, R1 had sustained a laceration to their shoulder and arm. Based on review of medical records, an additional wound assessment was conducted. In the assessment there are no indications of areolar tissue violation, no fascia violation, no foreign bodies/materials, no muscle damage, no underlying fracture and no vascular damage noted. In addition, R1's family member agreed that they did not wish for R1 to undergo significant interventions, only wound and comfort care. Due to contradicting information gathered and a lack of corroborating evidence the allegation is found to be unsubstantiated.

LPA's Tobola & Mutialu conducted a separate case management to address the general neglect/lack of supervision.

A finding that the complaint allegations, complaint alleges staff did not seek resident timely medical attention and neglect/lack of supervision resulted in resident sustaining a severe injury 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240122094705
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: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
87211(a)(1)
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A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified.. This requirement was not met as evidence by:** Based upon review of facility
and CCLD records, it was found that the
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Administrator failed to follow proper reporting requirements for incidents. Administrator agrees to conduct an in-service training for all staff on reporting protocols and incident report review to clear deficiency. Signed training to be submitted to CCLD by POC date 5/3/2024.
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facility failed to properly complete and report an Unusual Incident Report LIC624 regarding resident R1 sustaining unwitnessed fall located in facility courtyard. This serves as a potential healthy and 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4