486804115-2-15-2024-21-AS-VBEI-D2NST3-20240221130848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804115
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:31:34 AM

Unfounded

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
02/13/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20240213095453

FACILITY NAME:	PACIFIC GARDENS AT UNIVERSITY		FACILITY NUMBER:	486804115
ADMINISTRATOR:	BERNARDINO, KRISTINE		FACILITY TYPE:	740
ADDRESS:	118 UNIVERSITY AVE		TELEPHONE:	(760) 296-7562
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kristine Bernadino		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Neglect/lack of supervision resulted in facility not meeting residents care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrives unannounced for the purpose of continuing the investigation of this complaint. LPA toured portions of the facility; reviewed documents and spoke with the staff. This complaint was initiated by medical personnel who expressed concern that the Resident, R1, arrived at a medical facility in a condition that suggests R1's hygiene had been neglected by caregivers prior to admittance. Today it was determined that R1 was sent out from this facility on 12/19/24 for medical reasons and has never returned; R1, subsequent to 12/19, has been hospitalized and in Skilled Nursing Facilities and is no longer a resident of this facility. Based upon statements, the complaint allegation is false and without a reasonable basis since R1 has not resided in this facility since 12/19/2024. Therefore, the complaint is UNFOUNDED. The complaint is DISMISSED.

Report Left.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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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