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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/29/2020
Date Signed: 12/29/2020 01:01:58 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200415141655
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:
12/29/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Deborah LucasTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Residents are not receiving care and supervision due to insufficient staff.
Egress door alarms are not working.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings on 12/29/2020 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, and conducted a tour of the facility. The investigation allegations are as follows:

1. Residents are not receiving care and supervision due to insufficient staff.
2. Egress door alarms are not working.
Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
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 6
Control Number 27-AS-20200415141655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/29/2020
NARRATIVE
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On 10/22/2020, an unannounced visit was conducted. During this unannounced visit, LPA Martinez observed four caregivers and one med-tech during the night shift. On this day, there was no floater, and 1 caregiver called out. There was no replacement for the caregiver who called out. As a result, one of the communities did not have a caregiver.

Furthermore, during a 10/22/2020 interview with staff 1 (S1), S1 reported resident 1 (R1) waited 30 mins to be fed due to not having enough staff working the prior week. Moreover, while touring the facility on 10/22/2020, LPA Martinez observed Central Valley and Carmel communities. During the observation of the two communities, resident 2’s (R2) brief was being changed. At this time, both Central Valley and Carmel communities were left unsupervised, as R2 requires two caregiver assistance for brief changes. LPA Martinez observed resident 5 (R5) walking around Central Valley unsupervised.

Resident 3 (R3) was bent over on wheelchair, and R3’s face was resting on wheelchair’s tire. Resident 4’s (R4) body was leaning up against the wall, and R4’s hands were grasping on the handrail. LPA Martinez also observed the Napa and Yosemite communities. There was only one caregiver overseeing Napa and Yosemite communities. Resident 6 (R6) was walking around Yosemite and Napa communities and shutting off the lights in the Napa community. The Napa common living room area was dark and there were no night lights in hallways or common resident walkways. Some Napa residents were watching TV in the dark in common living room area. During the tour, Napa lights were turned on.

LPA Martinez observed active residents were left unsupervised due to the facility not being fully staffed. The facility did not ensure the facility was fully staffed on 10/22/2020 and did not ensure residents’ needs were being met. In addition, on 10/22/2020 Deborah Lucas returned to facility after her normal work shift in response to being notified LPAs Martinez and Johnson were at facility. Two staff members arrived at the same time as Deborah Lucas.

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

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20200415141655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/29/2020
NARRATIVE
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During the 10/22/2020 unannounced visit, the local fire department was called out to the facility due to a gas smell in the kitchen area. After this visit, LPA Martinez also requested a fire clearance inspection. The fire inspection included to test egress doors. It was learned that Carmel egress door was not working. It was learned that Carmel door can be open due to egress system security not working.

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

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20200415141655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/30/2020
Section Cited
CCR
87705(4)
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87705(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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The administrator agrees to review daily work schedules and email a monthly staffing report to CCL until 05/31/2021. Monthly report will be due at the end of each month.
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This requirement is not met as evidenced by: Based on observation and interview: the licensee did not provide adequate number of direct care to residents. This poses an immediate health, safety, or personal rights risk to residents in care.
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The administrator agrees to email first report by POC date 01/31/2021. The administrator agrees to send LPA statement of the monthly report due dates by 12/30/20.
Deficiency Dismissed
Type B
01/12/2021
Section Cited
CCR
87307(5)
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87307 Personal Accommodations and Services:(5) Night lights shall be maintained in hallways and passages to non private bathrooms. This requirement was not met by:
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The administrator agrees to ensure hallways and common areas in Napa have sufficient lighting. Picture of Napa night lights is due by POC date 01/31/21.
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Based on observation: the licensee did not ensure night-lights were in hallways. This poses a potential health, safety, or personal rights risk to 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/15/2020 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20200415141655

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:
12/29/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Deborah LucasTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Residents are not allowed to go out to the back patio because sidewalks are uneven (tripping hazards).
Facility is not training new employees.
Residents are not taking medication and becoming aggressive.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings on 12/29/2020 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, and conducted a tour of the facility. The investigation allegations are as follows:

1. Residents are not allowed to go out to the back patio because sidewalks are uneven (tripping hazards).
2. Facility is not training new employees.
3. Residents are not taking medication and becoming aggressive.
Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20200415141655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/29/2020
NARRATIVE
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LPA Martinez conducted a tour with Deborah Lucas around the outside grounds. LPA Martinez did not observe any tripping hazards on sidewalks. LPA Martinez did not observe uneven sidewalks during this tour. Moreover, Staff 3 reported residents can go out to the back patio.

LPA Martinez requested five new staff record training documents. Staff 1 (S1), staff 2 (S2), staff, 3 (S3), staff 4 (S4), and staff 5 (S5) met the 10-hour initial training requirement. LPA Martinez interviewed staff 1 (S1). Staff 1 reported all training was conducted. S1 reported if additional help/training is needed during a work shift, help/training will be provided. S2 reported no issues or concerns on the received training. S2 reported receiving adequate training.
During interviews, caregivers reported residents are given their medications daily. Caregivers reported resident’s do act aggressive at times although it is not a result of not taking their medications.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegation is unsubstantiated.

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 Martinez.

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

DATE: 12/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6