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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:23:22 PM


Document Has Been Signed on 08/26/2024 01:23 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:MCGRANAHAN, JULIETFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 58DATE:
08/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Juliet McGranahan, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 08/26/2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced for the purpose of conducting a case management inspection.

LPA was greeted by Juliet McGranahan, Administrator. LPA and Administrator toured the facility and made observations during the inspection. The facility was found to be clean and a comfortable temperature, however LPA found the facility did not have safeguards in place to protect the residents from hazards kept in the kitchen.

CCL received an incident report on 8/1/2024 stating that resident R1 accidentally ingested dish soap after accessing the kitchen while caregiver was busy with another resident. R1’s Physician’s Report states that R1 is at risk of allowed direct access to personal grooming and hygiene products and R1 is in a Dementia Care Unit where soaps should be safely secured. Per Title 22 regulation 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. The facility did not store toxic substances so that they were inaccessible to R1. Deficiency cited (see 809-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.

Continued on 809-D

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/26/2024 01:23 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: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2024
Section Cited
CCR
87705(f)(2)

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87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Facility to submit plan for conducting staff training on how to properly store toxic materials and items that could en danger residents by
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This requirement is not met as evidenced by:
Based on self-reported incident report, the licensee did not comply with the section cited above in that soap in kitchen area was accessible to residents, which poses/posed an imminent health, safety or personal rights risk to persons in care.
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08/27/2024 and training to take place no later than 08/30/2024 with a copy of training materials and sign in sheet of participants submitted to CCL by 09/03/2024.

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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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
LIC809 (FAS) - (06/04)
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