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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:24:04 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
03/07/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210307132124
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: 59DATE:
06/10/2021
UNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:D. LucasTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident AWOL'd from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Albert Johnson conducted an unannounced visit to delivering investigation findings. LPA explained the purpose of today’s visit is to deliver final findings on the above allegation.

Based on interviews conducted and records reviewed, LPA Johnson was able to establish that the information shared during an interview on 03/02/2021 about a matter not related to this complaint an AWOL was discussed. LPA review records and confirmed that the AWOL was reported to the department.

On 6/18/2020 an unusual incident was reported to the department regarding R1, it was reported by the facility that R1 eloped from the facility at approximately 9:30pm and was out of the community for approximately two hours. Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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
Control Number 27-AS-20210307132124
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: 06/10/2021
NARRATIVE
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 This is the inform that was substantiated on the report dated 10/30/2020, the facility was given a plan of correction and the citation was cleared on 11/3/2020. As a result of the continued AWOL'S and aggressive behaviors, R1 was going to relocate to another facility for a higher level of care. R1's medications were adjusted and R1 is not exit seeking like before and therefore has been allowed to stay at the facility. LPA was unable to establish an exact date for the reported AWOL allegation.

The department has determined based on the above information that the allegation is unsubstantiated, 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.

Exit interview and copy of report provided to facility staff
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2