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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/03/2025
Date Signed: 01/03/2025 03:21:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/01/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20241101083738
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: 65DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Resident Care Director, Lorena MadrigalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff handles residents in a rough manner
INVESTIGATION FINDINGS:
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At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility staff handles residents in a rough manner.” Report received on 11/01/2024 alleged that facility staff have been observed to handle residents in a rough manner, and stated that facility staff have been seen squeezing residents’ arms to get them to stop doing something.

LPA conducted staff interviews. 4 of 6 staff interviews conducted stated that they have seen residents be handled in a rough manner and/or spoken to disrepectfully.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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 3
Control Number 21-AS-20241101083738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
VISIT DATE: 01/03/2025
NARRATIVE
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Continued from LIC9099

Interview conducted with Executive Director stated that they have not observed or witnessed these incidents firsthand but had multiple staff members report incidents to management.

Based on interviews conducted, this allegation is Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report,LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241101083738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities: (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include:
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based on interviews conducted, Licensee did not ensure residents' personal rights. This is an immediate health and safety risk to residents in care.
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Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3