486803645-1-3-2025-21-AS-VBEI-DD7QX4-20250123113252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/03/2025
Date Signed: 01/03/2025 03:14:58 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
09/06/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240906144108

FACILITY NAME:	PACIFICA SENIOR LIVING VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	MCGRANAHAN, JULIET		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 65	DATE:	01/03/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Resident Care Director, Lorena Madrigal		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Neglect resulting in pressure injuries

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, "Neglect resulting in pressure injuries." Report received on 09/06/2024 stated that Resident 1 (R1) was isolated for COVID-19 from 08/25/2024 to 09/02/2024. On 09/01/2024, facility staff reported a smell and R1 was sent to the ER on 09/02/2024 where they were diagnosed with an unstageable wound on their sacrum.

LPA conducted staff interviews. 1 out of 8 staff interviews conducted revealed that on 08/29/2024, redness was observed by facility staff who notified the medication technician on duty.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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)

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Control Number 21-AS-20240906144108

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

The medication technician on duty provided facility staff with topical barrier cream to apply to R1 on 08/29/2024. Review of R1’s medication authorization record (MAR) showed that R1 had an ointment prescribed “as needed” for redness but the record did not indicate or show that an ointment was administered for R1 on 08/29/2024. Subsequently, there was no additional written documentation notated on R1’s MAR or progress notes to indicate that a change in skin condition was observed and that barrier cream was applied. Additional interviews also revealed that on 08/31/2024, another facility staff observed R1 to have a dark spot that was purple, brown, and leaking. This facility staff notified the medication technician on duty who stated they would notify management. Review of facility documents showed that on 09/01/2024, R1's nurse practitioner was faxed to notify them of the observation. Review of incident report dated 09/02/2024 stated that facility staff notified R1’s doctor of the wound on 09/01/2024 and that R1’s nurse practitioner called the facility on 09/02/2024 to request for R1 to be sent out to the hospital for an unstageable pressure wound on the coccyx area. Review of progress notes did not show any documentation or notification of a sore being observed for R1 by facility staff. Review of documentation also showed that seven staff were written up for failing to notice the wound on R1’s back.

Based on interviews conducted, document review, and observations made, 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 deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An informal meeting will be scheduled at a later date between the Facility and the Department to be held at the Santa Rosa Regional Office.**

Exit interview conducted. Copy of report, LIC811 (Confidential Names), 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 Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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)

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Control Number 21-AS-20240906144108

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 87466	1 2 3 4 5 6 7	87466 Observation of the Resident: Licensee shall ensure...residents are regularly observed for changes...& that appropriate assistance is provided...Licensee shall ensure...changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement was	1 2 3 4 5 6 7	Licensee to schedule training with approved outside vendor for all care staff regarding observation of a resident and proper documentation. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Trainer, Date of Training, Topics, Job Role,
	8 9 10 11 12 13 14	not met as evidenced by: based on interviews, records & observations, Licensee did not ensure that facility staff responded appropriately to observations of R1's wound resulting in an unstageable injury. This is an immediate health & safety risk to residents in care.	8 9 10 11 12 13 14	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 Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 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)

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