507004251-6-28-2021-27-AS-SDOB-C4JMPP-20210702094726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/25/2021
Date Signed: 06/28/2021 10:04:54 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
03/25/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210325164357

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: 60	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Deborah Lucas		TIME COMPLETED:	11:46 AM

ALLEGATION(S):

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Facility is not responding to calls from family timely.
Facility did not provide comfortable furnishings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Pacifica Senior Living Modesto to deliver the finding of the above allegations. LPAs met with Executive Director (ED) Deborah Lucas and Office Manager(OM) Teresa Pettapiece.

The initial 10 day Visit was conducted on 3/29/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that the facility is not responding to calls from family timely and that the facility did not provide comfortable furnishings.

9099 CONT. >>>>>>>>>>>>>>>>>

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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-20210325164357

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: 06/25/2021

NARRATIVE

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9099 CONT>>>>>>>

LPA interviewed OM, ED, and two residents. LPAs reviewed documents of communication logs. Communication logs notated when calls were received, who received them, and brief nature of contact. LPAs observed logs notating notes from caregivers. Documents show when/if a caregiver or staff had communication with responsible parties of resident. LPAs found no evidence that facility was not responding to calls in a timely manner.

LPAs conducted a physical plant inspection on 3/29/2021. LPAs observed comfortable, well maintained furnishings for the residents in both the common areas and in residents rooms. LPAs observed 2 rooms in Assisted Living area and 2 rooms in Memory Care Area. LPAs interviewed 8 residents, 7 of which responded to be satisfied with furnishings. The 8th resident did not respond to question. LPAs found no evidence that comfortable furnishing were not provided to residents.

Therefore, the allegation that the facility was not responding to calls in a timely manner and the facility did not provide comfortable furnishings is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be UNSUBSTANTIATED.

An exit interview was conducted with Administrator and a copy of this report 9099-A and Appeal Rights was provided to the Administrator via email.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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