507004251-12-29-2020-27-AS-KHOS-BX2K8Z-20210107064135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/28/2020
Date Signed: 12/29/2020 08:44:23 AM

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
10/02/2020 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20201002161641

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: 58	DATE:	12/28/2020
		UNANNOUNCED	TIME BEGAN:	03:24 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Sexual abuser, resident, is not being supervised.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 27-AS-20201002161641

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: 12/28/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/30/2020 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services(f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to complete 30 min checks on R1 and send daily check in log sheet. The administrator agrees to conduct a training on R1's care and supervision plan with R1's direct care staff.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure Care and supervision was being provided to residents in care. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agrees to email daily 30 min check in's starting 12/30/2020. Administrator agree to email training materials to LPA by 01/12/2021.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20201002161641

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: 12/28/2020

NARRATIVE

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During the investigation, it was learned the facility was not supervising resident 1 (R1). R1 has a history of sexual and aggressive behaviors, and in June of 2020 R1 sexually assaulted another resident. Furthermore, the facility did not implement a safety plan to prevent another sexual assault. As on 09/23/2020, R1 was found sleeping on an empty bed in a female resident’s room.

During various interviews, staff reported not receiving care and supervision instructions for R1’s sexual and aggressive behaviors. Staff 1 (S1) reported not being given any care and supervision instructions for R1. Staff 2 (S2) reports not being instructed to follow a care and supervision plan for R1. Staff 3 (S3) reports not being informed about a care and supervision plan for R1. Staff 4 reported not receiving any care and supervision instructions for R1.

On 12/26/2020, Executive Director Deborah Lucas, reported the facility did not implement a safety plan for R1. In addition, Deborah Lucas reported she did not schedule additional staff to assist R1. Moreover, Deborah Lucas reported R1 was not moved to a different community to avoid other sexual assault. As a result, the facility did not supervised R1, and allegation: sexual abuser, resident, is not being supervised is substantiated.

In addition, 87464 Basic Services (f)(1) was previously cited on 10/22/20 for sexual assault/lack of care and supervision. 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 via telephone and a copy of this report was provided to Deborah Lucas 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: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
10/02/2020 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20201002161641

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: 58	DATE:	12/28/2020
		UNANNOUNCED	TIME BEGAN:	03:24 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident had unexplained bruising on her back.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings 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 allegations with Deborah Lucas.

Throughout the course of the investigation, interviews were conducted and facility documents were reviewed. The investigation allegations are as follows:

1. Resident had unexplained bruising on her back.

Throughout the investigation, it was learned that resident 2 (R2) sustained a bruise on back prior to moving into the facility. Additionally, there are no other reports that R1 was physically assaulted at the facility.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20201002161641

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: 12/28/2020

NARRATIVE

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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 allegations are unsubstantiated.

An exit interview was conducted with Deborah Lucas via telephone and a copy of this report was provided to Deborah Lucas 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: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 5