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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804115
Report Date: 08/15/2023
Date Signed: 08/15/2023 10:11:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/18/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230718095742
FACILITY NAME:PACIFIC GARDENS AT UNIVERSITYFACILITY NUMBER:
486804115
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:118 UNIVERSITY AVETELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ronna DeVeraTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident in care sustained unexplained bruises
Staff isolate residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Caregiver DeVera and discussed the disposition. R1 has been observed with discoloration on finger tips of an unknown origin; Hospice Nurse evaluation conducted on 7/24/2023 determined the dark color to be "unknown cause;" R1 has not provided an explanation for the "bruises;" LPA found no evidence that the discoloration was due to staff abuse or neglect; During site visits conducted on 7/24 and 8/8 LPA observed 2 residents in common areas of the facility and 4 residents in their rooms; Interviewed residents indicated to LPA that they were in their rooms by choice and that they had access to the common areas if that was their choice. Although the allegations may be true, based on statements and documents reviewed, there is not a preponderance of evidence to prove the allegations are or, are not, true. Therefore, the allegations are UNSUBSTANTIATED.

Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/18/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230718095742

FACILITY NAME:PACIFIC GARDENS AT UNIVERSITYFACILITY NUMBER:
486804115
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:118 UNIVERSITY AVETELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ronna DeVeraTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident is not provided proper incontinence care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Caregiver DeVera and discussed the disposition. Complainant alleges that R1 has been observed in wet and soiled clothing and that R1 is not receiving proper incontinent care. During unannounced site visits conducted on 7/24 and 8/8, LPA noted R1 and R1’s room and bedding emitting a strong odor of urine; During the 8/8 visit, staff donned masks prior to entering R1’s room due to the urine odor; Hospice notes from 7/24 note R1’s bed smells of urine and that R1 has history of refusing shower and changing. Based upon documents, statements, and observations, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. 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.

Report left.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230718095742
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PACIFIC GARDENS AT UNIVERSITY
FACILITY NUMBER: 486804115
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2023
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence. … the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. ****Based upon observations and documents, this
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Administrator to submit a plan or correction that addresses how the facility will comply with the requirements of 87625 going forward. Written plan to be submitted to CCL by POC date in order to clears this deficiency.
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requirement has not been met as evidenced by: R1’s bedding was noted to smell of urine on 7/24 and 8/8/23 by Licensing Program Analyst and Hospice Nurse. This posed an immediate risk to health and personal rights of clients 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.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3