<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 06/25/2021
Date Signed: 07/08/2021 07:47:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 60DATE:
06/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director, Deborah LucasTIME COMPLETED:
11:46 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced case management visit. LPA met with Executive Deborah Lucas and informed her of the purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation 27-AS-20210325143205.

The following deficiency was discovered:

Based on review of resident weight records, resident were not being weighed on a monthly basis according to their written protocol. Per their Program Plan notated in Resident Care Policy 7.33, “…..residents will be weighed monthly,…to identify significant weight loss variances and ensure proper interventions are implemented.”. Per interview with ED, Deborah Lucas, weights were not taken for several months in 2020 and January 2021, due to COVID outbreaks in the facility due to staff becoming ill. Records reviewed and interviews conducted confirm no designation or plan was made by the ED during these months to ensure the residents needs are met and the Program plan is adhered to.

Deficiencies are cited, per Title 22 Regulations, and can be found on 9099-D and appeals right given. An exit interview was conducted with Executive Director Deborah Lucas, a copy of this report will be provided along with Appeal Rights.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2021
Section Cited

1
2
3
4
5
6
7
87208 Plan of Operation(a)Each facility shall have and maintain a current... written plan of operation ... A copy of the Admission Agreement...3)Statement of admission policies and procedures regarding acceptance of persons for services.
8
9
10
11
12
13
14
This requirement was not met by: Based on interviews and file reviews, the licensee did not adhere to plan of operation/admission agreement. This posed a potential health and safety risk to the residents in care.
8
9
10
11
12
13
14
Type B
06/25/2021
Section Cited

1
2
3
4
5
6
7
87411(a) Personnel Requirements-General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
8
9
10
11
12
13
14
This requirement was not met by: Based on interviews and file reviews, the licensee did not ensure there was sufficient staff in numbers, and competent to provide the services necessary to meet resident needs. This posed a potential health and safety risk to the residents in care.
8
9
10
11
12
13
14
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited

1
2
3
4
5
6
7
87405 (b) – Administrator – Qualifications and Duties
(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.

8
9
10
11
12
13
14
This requirement is not met as evidence by: Based on observation and interview the licensee did not maintain a plan to ensure resident's needs are met through clear definition of responsibility, delegation, and supervision which poses an immediate risk to health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3