486803645-11-17-2023-21-AS-BMOS-CXTSRW-20231122130701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 11/17/2023
Date Signed: 11/17/2023 02:06:04 PM

Unsubstantiated

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
09/18/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230918111148

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: 72	DATE:	11/17/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Administrator, Noel Factor		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not ensure that residents are provided care in a timely manner.
Staff do not ensure that residents receive their medication(s) as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Noel Factor, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff and a sample of residents. LPA reviewed a sample of Medication Administration Record (MAR) for 5 residents in care and reviewed facility documents. LPA conducted a tour of the facility on October 10, 2023.

Complaint alleges that Staff do not ensure that residents are provided care in a timely manner. Based on the interviews that were conducted, LPA could not prove or disprove the allegation. LPA reviewed the staff and resident roster and found those to be appropriate. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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-20230918111148

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: 11/17/2023

NARRATIVE

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LPA reviewed the Staff Schedule and found that to be appropriate. LPA interviewed staff members that care for residents which yielded no additional information to corroborate the allegation. LPA conducted a tour of the facility on October 10, 2023 and found staff caring for the residents in a timely manner. Furthermore, activities were being conducted on said date.

Complaint alleges that Staff do not ensure that residents receive their medication(s) as prescribed. Based on a Medication Administration Record (MAR) review of a sample of resident medications, LPA could not corroborate the allegation. In addition, LPA could not prove or disprove the allegation.

A finding that the complaint allegation of Staff do not ensure that residents are provided care in a timely manner and staff do not ensure that residents receive their medication(s) as prescribed are unsubstantiated meaning that although the allegations 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 allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC9099 (FAS) - (06/04)

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