507004251-4-29-2021-27-AS-CACL-C2Q24H-20210504170358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 04/29/2021
Date Signed: 04/29/2021 04:16:17 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
10/22/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201022100608

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:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff not supervising resident resulting in multiple falls

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) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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 4

Control Number 27-AS-20201022100608

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: 04/29/2021

NARRATIVE

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On 10/01/2020, R1 was sent to the emergency room due to falling next to his bed, which R1 was diagnosed with a subdural hematoma. R1 was discharged from the hospital on 10/02/2020. After returning from the hospital on 10/02/2020, R1 slipped out of his chair and landed on the ground and at 3:30 PM R1 was observed on the floor next to his bed. On 10/05/2020, R1 had an un-witnessed fall at the facility’s back patio. Facility staff were unaware that R1 was outside, and it was determined it was unknown how long R1 was outside. R1 was sent to the hospital on 10/05/2020 and was admitted into the intensive care unit. It was learned R1 was diagnosed with a mild interval enlargement of the left hemispheric subacute on chronic subdural.

The facility’s 7.69 fall management policy states, “ the staff member who responds to the fall is to complete an occurrence first responder work sheet, and the Resident Care Director (RCD) will use the Post-Fall Tracking & Intervention form to analyze each fall and implement new interventions as warranted. This process will be initiated upon the first fall and analyze each subsequent fall as directed on the form. During the investigation and file review Post-Fall Tracking & intervention forms were not found in R1’s file. Moreover, R1’s Needs and Service Plan report did not include a fall prevention plan and stated no falls.

Based on facility documents and file reviews, three hospitalization reports reported the various information: R1 was a fall risk, fall prevention instructions, and head injury instructions However, the facility did not conduct reappraisals after R1's falls. Furthermore, based on the provided Needs and Service Plan, the facility did not implement a fall prevention plan for R1. As a result, there is a preponderance of evidence to prove that the facility did not provide care and supervision to R1.

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) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20201022100608

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: 04/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/30/2021 Section Cited CCR 87463(a)(3)(c)	1 2 3 4 5 6 7	87463 Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.(3)Any illness, injury, trauma, or change in the health care needs.(c) The licensee shall arrange a meeting with the resident, the resident’s representative...if any, when there is significant change in the resident’s condition.	1 2 3 4 5 6 7	The administrator agrees to complete Relias training on reappraisals and observation of residents by POC date 05/29/2021. The administrator agrees to email LPA training topics and agenda to LPA by 04/30/2021
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and records review, the administrator did not ensure R1's was being reappraised after falls and implement a fall prevention plan. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14
Type A 04/30/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...	1 2 3 4 5 6 7	The administrator agrees to complete Relias training on reappraisals and observation by POC date 05/29/2021. The administrator agrees to email LPA training topics and agenda to LPA by 04/30/2021
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and records review, the administrator did not ensure R1's was being observed for physical changes and meeting R1's fall prevention needs. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14

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) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
10/22/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201022100608

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:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Facility failed to safeguard resident’s belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez contacted the facility via telephone to deliver investigation findings on 04/29/2021 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the complaint findings with Deborah Lucas.

Throughout the course of the investigation, the Department conducted interviews and reviewed facility documents. R1's Client/Resident Personal Property and Valuables form did not state wedding ring or bed rails. As a result, there was not a perponderance of evidence to determine the ring was lost or stolen in the facility. Additionally, there was no indication R1's resposible person provided bed rails. R1's glasses and hearing aids are currently in the facility. R1's personal belongings can be pick up by his responsible person.

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 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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 4