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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 05/27/2021
Date Signed: 05/27/2021 12:02:44 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
12/18/2020 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20201218101048
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:
05/27/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Deborah LucasTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility not administering medication as required.
Facility is not following resident's primary care physician medication orders.
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, it was learned R1 was given a medication order for Ensure Boost Plus 1. The Ensure Boost Plus 1 order on the Medication Administration Record states, "drink Ensure Boost Plus 1- bottle per day." Additionally, a facility note dated 12/17/2020, reported R1 had a supply of Ensure Boost Plus 1, and they were being stored in the Yosemite community refrigerator. However, R1's October, November, and December medication administration record reflected R1 was not being administered Ensure Boost Plus 1.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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)
Page: 1 of 3
Control Number 27-AS-20201218101048
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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The October, November, and December MAR administration entries were left blank. Moreover, witness 1 (W1) called the facility to inquire about replenishing R1's Ensure Boost Plus 1 supply on 12/17/2020. W1 was informed R1 had a supply of Ensure Boost Plus 1 by facility staff. It was also noted that facility staff would monitor if R1 was being offered 1 Ensure Boost Plus 1 per day per physician’s order. However, R1’s December MAR sheet continued to be left blank after 12/17/2020. As a result, the facility did not ensure R1 was being administered Ensure Boost Plus-1 and following R1’s primary care physician’s medication orders.

As a result of this investigation, the Department finds these allegations to be substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations and appeals rights given.

In addition, 87465(a)(5) Incidental and Medical and Dental: 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.


Exit interview conducted and copy of report provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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)
Page: 2 of 3
Control Number 27-AS-20201218101048
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: 05/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental and Medical and Dental (a)(5) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The administrator shall assist residents with self administered medications as needed.
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Facility administrator has completed medication training last month. POC completed for Incidental and Medical and Dental. 01/8/2021 training materials were emailed to LPA.
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This requirement is not met as evidenced by:
Based on interviews and records review, the administrator did not ensure R1 was being administered Ensure Boost Plus 1 as prescribed. This posed an immediate health and safety risk to R1.
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06/14/2021
Section Cited
CCR
874657(7)
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3