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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 04/14/2021
Date Signed: 04/15/2021 08:27:52 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
10/19/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201019113049
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:
04/14/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Deborah LucasTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Due to insufficient staffing resident sustained a fall and was seriously injured.
Due to staff neglect, resident was able to leave a secured egress door and was later found in the patio.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Avelina Martinez and Arlene Garcia contacted the facility via telephone to deliver investigation findings on 04/14/2021 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, reviewed facility documents, and conducted a tour of the facility. During resident 1’s (R1) 10/05/2020 unwitnessed fall investigation, interviews were conducted with facility staff. Through interviews it was reported due to being short staff residents are left unsupervised on a daily basis, and the facility is unsafe for residents. Three out of twelve facility staff reported due to being short staff, they were unable to complete their caregiving duties, such as, conduct showers, clean residents, feed residents, and supervise residents. In addition, during an interview, it was stated, “the residents can open the doors despite the door alarms, and they go outside by themselves…sometimes the caregivers are unaware residents are outside.” Witness 1 (W1) reported visiting the facility multiple times prior to Covid-19 visitation restrictions. W1 reports while sitting outside with a Pacifica Senior Living Resident, W1 observed other residents left unsupervised for a long period of time.
Substantiated
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: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 5
Control Number 27-AS-20201019113049
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: 04/14/2021
NARRATIVE
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Regarding R1’s fall on 10/5/2020, three out of twelve-facility staff reported it was unknown how long R1 was laying on the ground outside. It was also reported it was unknown how R1 got outside. Doctor’s Medical Center of Modesto’s notes report fall with unknown downtime. The American Medical Response (AMR) report, states, “it was unknown how long R1 was outside at the patio area.” The AMR report also, indicated staff reported there is no one that does rounds to check the outside. As a result of the lack of care and supervision, R1 was found laying supine on the dirt by a maintenance staff and suffered a serious injury.

Additionally, R1 had a fall on 10/01/2020 and was diagnosed with a brain bleed. Due to the 10/01/2020 fall, the facility’s Resident Care Director (RCD) implemented a 1 hour-check directive for R1. It was also reported by the Resident Care Director that this directive was implemented to make sure R1 did not sustain other falls as a brain bleed diagnoses is serious. However, at the 10/05/2020 un-witnessed fall, A hospital CT scan indicated R1 had a mild interval enlargement of the left hemispheric subacute on chronic subdural hematoma. R1 also was transferred to an Intensive Care Unit (ICU) for 2 days, which R2 was later transferred to a step-down care unit. On a 10/12/2020 discharge note, it was noted R1 needed max assistance with feeding and mobilization and home health care.

Based on records reviews and interviews obtained throughout the investigation, the allegation that due to insufficient staffing resident sustained a fall and was seriously injured was substantiated. There was a preponderance of evidence to prove that the facility did not provide care and supervision to R1. Multiple staff reported not being able to provide care and supervision due to being short staffed. In addition, based on information obtained through record reviews and interviews, there was a preponderance of evidence to prove that resident was able to leave a secured egress door, therefore the allegation was substantiated. As a result, R1 sustained a fall with a serious injury, which R1 later passed away due to other complications.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20201019113049
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: 04/14/2021
NARRATIVE
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The following deficiencies are cited, per Title 22 Regulations, and can be found on 9099-D report. 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.

As a result of this incident, R1 sustained serious bodily injuries, the violation warrants a civil penalty assessment. At this time, the civil penalty assessment is under review, and a civil penalty determination is pending by the Department. Once the civil penalty assessment has been determined, an LPA will return at a future date to assess the civil penalty.

In addition, 87464 Basic Services (f)(1) was previously cited on 12/28/2020. Therefore, a civil penalty shall be assessed for a repeat violation within a 12-month period during this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20201019113049
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: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/16/2021
Section Cited
CCR
87464(f)(1)
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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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The administrator agrees to review residents needs and service plans and go over with plans with TSP analyst. The administrator agrees to email LPA a written statement of the needs and service plan agenda by 04/16/2021. The administrator will provide LPA a report of residents' needs and service plan review by 05/07/2021 via email
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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 while outside, which R1 had a fall with unknown downtime while outside. This posed an immediate health and safety risk to R1.
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Type A
04/16/2021
Section Cited
CCR
87405(h)(5)
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87405(h)(5) Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to:(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement is not met as evidenced by:
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The administrator agrees to review administrator responsibilities 87405(h)(5).responsibilities 87405(h)(5) and email review statement to LPA by 04/16/2021.
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Based on interviews and records review, the administrator did not ensure R1's physical and mental well-being and needs were being maintained while outside, which R1 fell while outside with unknown fall down time. This posed an immediate health and safety risk to R1.
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The administrator agrees to Implement a communication log in regards to residents' whereabouts for facility staff. The administrator agrees to email LPA a report of the communication log by 05/07/2021
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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 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
10/19/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201019113049

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:
04/14/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Deborah LucasTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
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9
a resident was assaulted by another resident while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings via telephone on 4/14/2021 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, and conducted a tour of the facility.Throughout the course of this investigation, the Department conducted interviews, reviewed facility and resident records. During the investigation, it was learned that Resident 2 (R2) was unable to provide details regarding alleged assault, and R2’s interviews were inconsistent . In addition, there were no witnesses to account to what occurred. Therefore, there is not a preponderance of evidence to determine R2 was assaulted by another resident.

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 violation(s) 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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5