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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/25/2021
Date Signed: 06/28/2021 10:03:42 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-20210325143205
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
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Executive Director, Deborah LucasTIME COMPLETED:
11:46 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not reporting incidents to resident's responsible party.
Resident is severly neglected.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced visit to deliver the findings of the complaint initiated on 3/25/2021. LPA met with Executive Director, Deborah Lucas.

The initial 10 day visit was conducted on 03/29/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged that a resident is severely neglected and that the facility is not reporting incidents to resident's responsible party. Although the facility weight logs revealed R1 lost 23 lbs. in one month, based on the facility records, staff interviews and hospital records, there was no evidence to support R1 was a victim of neglect. Records reviewed showed that the facility took the measures to contact the physicians and hospitals caring for the resident. Review of resident records showed facility staff adhered to instructions recommended by physicians. Interviews conducted confirmed staff notified responsible parties of R1.
Based on the information provided through interviews, records reviewed, and facility tour, the allegations that a resident is severely neglected and that the facility is not reporting incidents to resident's responsible party is UNFOUNDED.

This agency has investigated the allegations noted. We have found them to be UNFOUNDED meaning they are false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. Exit interview held, a copy of report given.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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