507004251-6-28-2021-27-AS-SDOB-C4JMPN-20210702094725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/25/2021
Date Signed: 06/28/2021 10:14:55 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:	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 did not report incidents to responsible party.

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.

It was alleged that the facility failed to report incidents to responsible party. RP stated that the facility failed to report to her that C2 recliner was broken and a replacement was ordered. LPAs reviewed documents for both C1 and C2. Documents indicate that C1 is the responsible party of C2. Documents show RP to be the responsible party for both C1 and C2 in the event of passing of both C1 and C2. Pre-appraisal and LIC 602 show that C1 does not have a diagnosis that would preclude C1 from acting as the responsible party for C2. C1 is a resident that chooses to live in facility to be with C2.
9099 CONT.>>>>>>>>>>>>>>>>>

Unfounded

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 C1, C2, and ED Lucas. C1, spouse of C2, reported that the issue had been resolved. C1 stated that the facility provided C2 with the requested recliner and kept C1 and C2 informed. LPAs reviewed the Caregiver notes. Caregiver documented when the recliner was received and that C1 and C2 were satisfied.

Based on interviews, facility had reported incidents to responsible parties, therefore the allegation was deemed UNFOUNDED. This agency has investigated the allegation noted above. The complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department therefore has dismissed the allegation.

Exit interview was conducted with ED Deborah Lucas and a copy of this report was provided along with a confidential names list.

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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