507004251-5-27-2021-27-AS-KHOS-C3KN3R-20210601100646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 05/27/2021
Date Signed: 05/27/2021 12:14:23 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
10/05/2020 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20201005111152

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: 59	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Deborah Lucas		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Administrator is the POA of a resident.
Resident has unexplained bruising.
Unexplained multiple falls.

INVESTIGATION FINDINGS:

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On 05/27/2021 at 11:30 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez identified herself and discussed the purpose of the visit and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, interviews were conducted and facility documents were reviewed. During an interview with witness 1 (W1), W1 reported being resident 1's (R1) power of attorney (POA). Witness 1 reported the facility administrator was not the POA. Additionally, facility documents named witness 1 as being the POA. Witness 1 signed R1's admission agreement as the POA. Witness 1 also reported she had no concerns with the care resident 1 was receiving 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) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20201005111152

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: 05/27/2021

NARRATIVE

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Moreover, LPA Martinez reviewed R1's facility narrative charting notes. It was learned R1 had fallen on 10/02/2020. R1 was observed on the floor by a care staff. A med-tech conducted an assessment and there were no cuts or bruising, and hospice was notified. On 10/05/2020 R1 slid out of his wheelchair while attempting to open door. R1 did not sustain any injuries from this fall and hospice was notified. R2 had a fall on 10/17/2020, and a med-tech conducted a head to toe check. There were no cuts or bruising and hospice was notified. Based on the file review there were no other recorded falls in October. On 10/23/2020, R2 had a bruise on chest and hospice was notified. Hospice staff conducted a facility visit to follow up on R2's bruise.

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 and a copy of this report was provided to Deborah Lucas.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

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