486803645-4-28-2022-21-AS-CFES-CDWU5U-20220428151718

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:17:25 PM

Document Has Been Signed on 04/28/2022 03:17 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 VACAVILLE		FACILITY NUMBER:	486803645
ADMINISTRATOR:	LEE-ALLMOND, MELODY		FACILITY TYPE:	740
ADDRESS:	431 NUT TREE ROAD		TELEPHONE:	(707) 449-1350
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	75	CENSUS: 62	DATE:	04/28/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Administrator, Melody Lee-Allmond		TIME COMPLETED:	03:17 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management visit and met with Administrator, Melody Lee-Allmond. The purpose of this Case Management visit is to follow up on three self-reported incidents/SOC-341s submitted to Community Care Licensing (CCL) by this facility. LPA and Administrator had previously discussed an incident involving Resident 1 (R1) and Resident 2 (R2) that occurred on 3/18/2022 where R1 and R2 had an altercation. Report states that R1 yelled inappropriate obscenities at R2. R1 then grabbed R2 by the wrists and started to grab R2's personal items out of her hand. R2 slapped R1 in the forehead. Staff were able to redirect residents. Per conversation with Administrator, R1 and R2 had not had altercations like this before. and facility protocols are to redirect residents and monitor. If another incident were to occur, residents will be reassessed for possible reassignment of House and appropriateness of placement. LPA spoke with Administrator and Resident Services Director regarding the incident that occurred on 4/12/2022 which involved another altercation between R1 and R2. Report was cross-reported to APS and states that R1 yelled obscenities at R2 then grabbed her wrist as R2 walked by. R2 responded by slapping R1 on the forehead. No injuries sustained by either party. APS determined that based on the information provided, case does not appear to have evidence of abuse therefore, case would not be pursued. Per conversation with Administrator and Resident Services Director, Facility is in contact with both families as well as R2's Physician, their one-on-one companion, and R1's Hospice agency. Facility has been in frequent contact with all parties to determine reassessment of care plan for both residents. Continued on LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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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
	VISIT DATE: 04/28/2022

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Continued from LIC809.

LPA spoke with Administrator and Resident Services Director regarding a third incident/SOC-341 involving Resident 3 (R3) and Resident 4 (R4) that occurred on 4/13/2022. Report states that R3 was having behaviors and approached R4. R3 pushed a dining room chair into R4's wheelchair and pushed them in their chest and left shoulder. R3 was redirected by staff successfully. No injuries noted. R3 and R4's responsible parties and physicians were notified.
Per conversation with Administrator and Resident Services Director, R3 just moved in and is still transitioning to their new environment. Facility is ensuring that staff monitors both residents for behaviors. Facility is in contact with both families.

No Deficiencies cited during visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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