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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:20:45 PM


Document Has Been Signed on 07/06/2022 04:20 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:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 59DATE:
07/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Resident Services Director, Solomae (Mae) MoraTIME COMPLETED:
03:30 PM
NARRATIVE
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While conducting an investigation at the facility, Licensing Program Analysts (LPAs) Felias and Arnhold following up on two documents submitted by facility.

Incident #1: LPA received an SOC-341 on 6/17/2022 regarding two residents that were in an altercation. Based on interviews and records reviewed, Facility staff responded immediately and were able to separate residents. Residents were escorted back to their houses with no further incidents. Facility has relocated the residents to prevent future altercations. Facility made all appropriate notifications per regulation.

Incident #2: LPA received an incident report on 6/27/22 regarding an incident that occurred on 6/19/22. The incident involved a resident leaving the facility unassisted and without staff knowledge. A search was conducted, law enforcement was notified, and the resident was found nearby unharmed.

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 immediate civil penalty in the amount of $250.00 has been issued for a repeat violation of
Health and Safety Code (HSC): Section 1569.312(d). The civil penalty will continue to accrue
$100 per day per violation until the violation is corrected.

Exit interview conducted. Copy of report, LIC-809D, LIC-421FC and Plan of Corrections discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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Document Has Been Signed on 07/06/2022 04:20 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: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited

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1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
Based on interviews conducted, the Licensee did not comply with the section cited above and did not ensure that staff knew the general
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whereabouts of R1. It was reported that R1 left the facility unassisted and without staff knowledge. A search was conducted and R1 was found unharmed. This poses an immediate risk to the health and safety of residents in care.
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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: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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