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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 12/28/2020
Date Signed: 12/29/2020 09:18:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PACIFICA SENIOR LIVING MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 58DATE:
12/28/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:24 PM
MET WITH:Deborah Lucas TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a case management tele-visit via telephone on 12/28/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation(s) with Deborah Lucas.

The purpose of the case management visit is to follow up on various deficiencies learned throughout a complaint investigation. The following deficiencies were discovered:


LPA Martinez requested all rent increase documentation from the facility. It was learned; the authorized representative was informed on 03/25/2020 via e-mail that as of 3/24/2020 R1’s base monthly rate would increase to $5,600.00. Per R1’s signed admission agreement, the facility shall give sixty (60) days’ prior written notice of any base monthly fee, fees for level care, or in the charges for optional services. The facility failed to follow the agreed residence and care admission agreement and failed to follow the 60-day written rent increase policy.

The facility did not adhere to Personal Property and Valuables policy stated on R1's admissions agreement. R1’s signed admission agreement included client/resident property and valuables LIC 621. However, the LIC 621 was not completed by the facility. Following the LIC 621, the admission agreement includes Section 1569.152 Health and Safety Code: which states, “ (d) a written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly.” The facility did not adhere to the signed admission agreement.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PACIFICA SENIOR LIVING MODESTO
FACILITY NUMBER: 507004251
VISIT DATE: 12/28/2020
NARRATIVE
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Furthermore, LPA Martinez reviewed 01/01/2020 thru 05/31/2020 medication MAR sheets. LPA Martinez learned that on May 29, 30, and 31st R1 was not administered the following medication: Pantoprazole Sodium, Trazodone, Levothyroxine, Centrum Silver. Melatonin was not administered on May 28, 29, 30, and 31st. The facility did not administer medication as prescribed.

Due to the above noted information, the following deficiencies were cited, per Title 22 Regulations, the deficiencies were cited on 809-D, and appeals rights given to the administrator.

In addition, 87465(a) (5). was previously cited on 06/02/2020. Therefore, a civil penalty shall be assessed for a repeat violation within a 12-month period during this visit.


An exit interview was conducted with Deborah Lucas. A copy of this report was provided to Deborah Lucas via email. LPA Martinez emailed the report to Deborah Lucas due to covid-19 precautionary measures. Deborah Lucas signed the report and emailed the report to LPA.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PACIFICA SENIOR LIVING MODESTO
FACILITY NUMBER: 507004251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2020
Section Cited

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87465 Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility... compliance with the following:(5) The licensee shall assist residents with. This requirement is not met as evidenced by:
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Based on interviews and records review, the licensee did not ensure R1 was being administered medication as prescribed. This posed an immediate health and safety risk to R1.
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Administrator will provide a copy of the electronic medication MAR procedures by 01/11/2021. Administrator will provide medication training materials to LPA by 01/11/2021.
Type B
03/11/2021
Section Cited

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87208 Plan of Operation(a)Each facility shall have and maintain a current... written plan of operation ... A copy of the Admission Agreement...3)Statement of admission policies and procedures regarding acceptance of persons for services.
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This requirement was not met by: Based on interviews and file reviews, the licensee did not adhere to plan of operation/admission agreement This posed an potential health and safety risk to R1 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2020
LIC809 (FAS) - (06/04)
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