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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 04/14/2021
Date Signed: 04/14/2021 05:08:10 PM

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: 56DATE:
04/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Deborah Lucas TIME COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs ) Avelina Martinez and Arlene Garcia contacted the facility via telephone to commence a case management call on 04/14/2021 due to COVID-19 and pre-cautionary measures. LPA Martinez identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

The purpose of the case management visit is to follow up on deficiencies found during a complaint investigation reference # 27-AS-20201019113049.

Resident 2 (R2) had an un-witnessed fall on 10/15/2020. The fall occurred on the PM shift at Carmel’s back patio. R2 suffered a skin tear to the left cheek; a skin tear to the right back side of hand; and a skin tear to the left thumb. After R2’s 10/15/2020 fall, a med-tech called the facility’s Resident Care Director (RCD) to inform her of the fall. The RCD determined R2 was not going to be sent out to the hospital due to her over the phone assessment of no signs of pain or head injury.



The facility Clinical 9 Medical Emergencies policy states the following: “ the resident will receive emergency medical care when needed to prevent further injury or illness…(3) The community summons emergency medical services (911) when the residents exhibits signs and symptoms of distress and/or on emergency condition…examples included, but are not limited to…(d) fall with deformity, severe pain, or head injury…(h) sudden onset of severe pain.” The facility emergency medical care and fall assessment did not prevent further injury or illness as stated on clinical 9 Medical Emergencies policy.

As it was noted, R2 suffered skin tears to the left cheek, and a 10/17/2020 hospital notes indicated R2 reported hitting head during fall incident. Moreover, two caregivers reported R2 was in pain and could not walk after the 10/15/2020 fall. It was also reported it took 4 caregivers to return R2 to his bedroom after the 10/15/2020 fall. One caregiver reported R2 needed to be sent out to the hospital after the 10/15/2020 fall.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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
VISIT DATE: 04/14/2021
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On 10/16/2020 R2 was sitting on a recliner, and a care staff observed a skin abrasion on top of right hand. A med-tech also reported purple discoloration to right eye with an abrasion. A med-tech provided first aid, although R2 was not sent out to the hospital until the next day. On 10/17/2020, R2 was sent out to the hospital due to pain and not being able to stand. A 10/17/2020 hospital note reported that R2 was diagnosed with a left femoral neck fracture, hip fracture and elbow injury. On 10/18/2020 a hip hemiarthroplasty was conducted. As a result, the facility did not ensure to provide care and supervision to R2, which caused R2 to sustain serious injuries. Furthermore, It was noted that R2’s responsible party was not called immediately after 10/15/2020 fall. During the investigation, it was learned that on 10/16/2020 the responsible party was informed of R2’s 10/15/2020 fall by the facility administrator. Facility policy Clinical-11 Fall Response policy states, “The responsible party is notified immediately.” The facility did not follow Clinical-11 Fall Response policy.

Based on documentation and interviews obtained throughout the investigation, it was determined the facility did not provide timely medical care as required, as R2 was not sent to hospital until 2 days after a serious fall.

Following deficiencies are cited, per Title 22 Regulations, and can be found on 809-D. A copy of this 809/D report and appeals rights were provided via e-mail to Deborah Lucas. An exit interview was conducted with Deborah Lucas via telephone, and a copy of this report was provided to Deborah Lucas via email, and an electronic email read receipt confirms receiving these documents.

As a result of the fall, R2 sustained serious bodily injuries, the violation warrants a civil penalty assessment. At this time, the civil penalty assessment is under review, and a civil penalty determination is pending by the Department. Once the civil penalty assessment has been determined, an LPA will return at a future date to assess the civil penalty. Additionally, 87466 Observation of the Resident: was previously cited on 06/02/2020. Therefore, a civil penalty shall be assessed for a repeat violation within a 12-month period during this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/15/2021
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis ...
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure R2 received timely medical care following a fall with serious injuries which posed an immediate health and safety risk to R2.
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Type B
04/15/2021
Section Cited

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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning When changes such as....physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person...
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure R2's responsible person was notified of R2's fall injuries & health condition in a timely manner, which posed an potential health and safety risk to R2.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (915) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2021
LIC809 (FAS) - (06/04)
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