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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 04/13/2021
Date Signed: 04/13/2021 11:29:27 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
01/21/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210121165503
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: 56DATE:
04/13/2021
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death.
staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings on 04/13/2021 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 Theresa Pettapiece.

Throughout the course of the investigation, the Department conducted interviews and reviewed facility documents. Beginning on 01/02/2021 hospice notes report resident 1's (R1) health was actively declining. Additionally, on 01/02/2021 hospice staff informed R1’s family of the transitioning and decline. On 01/04/2021 Hospice staff began providing grieving/emotional support to R1’s family. It was also learned that the staff did not mismanage R1's medication. R1's PRN and routine Lorazempam was administered at the correct times.
As a result, the Department has investigated the complaint alleging questionable death. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. 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.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
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
01/21/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20210121165503

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: 56DATE:
04/13/2021
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staff resulting in resident's needs not being met.
Facility has inadequate diapering supplies.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings on 04/13/2021 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 Theresa Pettapiece.

Throughout the course of the investigation, the Department conducted interviews and reviewed facility documents. Witness one (W1) reported not having issues with the brief supply. In addition, W1 recently visited the facility, and reported while at the facility resident 1 (R1) and resident 2 (R2) did not have soiled brief incidents. Witness two (W2) reported resident 3 (R3) and resident 4 (R4) are treated well and has no complaints about the care. Witness 3 (W3) reported resident 5 (R5) is well taken care of and has no complaints about the care or brief supplies. Witness 4 reports not having issues with staffing. Witness 4 reports while visiting the facility, there is always cares staff.

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 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 2 of 2