507004251-6-11-2021-27-AS-CACL-C3ZMQP-20210615094903

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:53:08 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
11/30/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201130163426

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:	06/11/2021
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Residents are not being administered medication due to insufficient staffing.
Med-Techs are administering morphine to hospice residents.

INVESTIGATION FINDINGS:

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On 06/11/2021 at 1:26 PM, 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. LPA Martinez reviewed 8 hospice resident files. In addition, LPA reviewed Morphine medication administration records (MAR), and determined morphine was being administered as required. Resident 1 (R1) was prescribed liquid morphine, and she was able to ingest medication independently. Moreover, there were no other morphine administration descrepiencies noted on resident 2,resident 3, resident 4, resident 5, resident 6, and resident 7 MAR's.

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: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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-20201130163426

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: 06/11/2021

NARRATIVE

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Based on interviews, there was not a preponderance of evidence to determine that residents are not receiving their medication due to lack of staff. Staff 1 (S1) reported residents are receiving their medications on time. S1 also, reported the Med-Tech department is fully staffed. Staff 2 (S2) reported she had no concerns about the medications being administered at the facility. Staff 3 reported she did not have any issues or concerns about the facility.

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: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC9099 (FAS) - (06/04)

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