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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 05/20/2021
Date Signed: 05/20/2021 10:31:58 PM

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 MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 60DATE:
05/20/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Theresa Pettapiece (BOM)TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia and Licensing Program Analyst (LPA) Albert Johnson conducted a case management visit on today's date for the purpose of investigating an incident that occurred on 4/16/2021 when R-1 AWOL'd from the facility. According to R-1's Physicians report, R-1 is not allowed to leave the facility unassisted.

LPAs observed residents engaged in activities and eating lunch. LPAs observed alarms functioning in the communities. LPAs tested alarms in Carmel community leading to kitchen. LPAs tested alarm on kitchen door leading to second hallway which leads to back exit. All alarms functioning. LPAs observed working motion camera positioned on back exit area. Back exit area for kitchen and personnel staff.

Deficiencies were cited on today's date 5/20/2021 and Civil Penalties assessed. Exit interview conducted. Appeal rights discussed and a copy given to the Administrator. A copy of this report was given to the Business Office Manager (BOM).
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
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: 05/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2021
Section Cited

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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)..."Care and supervision" means the facility assumes responsibility for,... ongoing assistance with activities of daily living ...

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This requirement is not met as evidenced by: Based on interviews and records review, the facility did not ensure R1's was being provided the required basic care and supervision as a result R1 AWOL'd out of facility unsupervised. This posed an immediate health and safety risk to R1.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2021
LIC809 (FAS) - (06/04)
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