507004251-4-13-2021-27-AS-AMAZ-C22PBW-20210413111100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 04/13/2021
Date Signed: 04/13/2021 11:11:27 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 MODESTO		FACILITY NUMBER:	507004251
ADMINISTRATOR:	LUCAS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	2325 ST PAUL'S WAY		TELEPHONE:	(209) 491-0800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS: 56	DATE:	04/13/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:17 AM
MET WITH:	Deborah Lucas		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Avelina Martinez contacted the facility via telephone to commence a case management call on 04/13/2021 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the allegation with Theresa Pettapiece.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation 27-AS-20210121165503. The following deficiency was discovered:

On 01/02/2021, resident 1's (R1) Lorazepam pill form was discontinued and a new liquid form order was given to the facility which, was Lorazepam Intensol 2 MG/M 30 ML “give 0.25 ML (0.5MG) by mouth every 8 hours routine for anxiety and give 0.25 ML (0.5MG) by mouth every 4 hours as needed for anxiety. Resident 1's (R1) written liquid count sheet has a Lorazepam balance and time discrepancy. The Lorazepam balance entries consist of the following: 01/05/2021 first entry at 1PM states 25 ML; the 01/05/2021 second entry at 12 PM states 20 ML; on 01/06/2021 entry at 12PM states 15 ML; on 01/07/2021 first entry at 12PM states 10 ML; the 01/07/2021 second entry at 3:45 states 0.25. As a result of the medication records review, the facility did not maintain R1’s medication record.

Deficiencies are cited, per Title 22 Regulations, and can be found on 9099-D and appeals right given. An exit interview was conducted with Theresa Pettapiece via telephone, and a copy of this report was provided to Theresa Pettapiece via email, and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

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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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: 04/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/19/2021 Section Cited	1 2 3 4 5 6 7	87465Incidental Medical and Dental Care(7) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure R1's medication records were being maintained. The liquid count sheet has balance and time discrepancies. This posed an potential health and safety risk to R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC809 (FAS) - (06/04)

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