507004251-10-30-2020-27-AS-KHOS-BUZM82-20201103082222

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 10/30/2020
Date Signed: 10/30/2020 03:05:34 PM

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
06/19/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200619123758

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: 58	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident awoled from the facility and was found by Modesto Police Department.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation on 10/30/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Deborah Lucas.

Throughout the course of the investigation, LPA conducted interviews with facility staff and reviewed documents. Based on the interviews and records review, LPA determined the facility did not ensure to monitor resident 1's (R1) activities, which resulted in R1 leaving the facility unattended. Furthermore, the Modesto Police Department posted a missing persons report on social media. R1 was found by the Modesto Police Department, which the Police Department also reported that R1 was found on social media.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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-20200619123758

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: 10/30/2020

NARRATIVE

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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations, and appeals rights given to Deborah Lucas.

An exit interview was conducted with Deborah Lucas. A copy of this report was provided to Deborah Lucas via email. LPA Martinez emailed the report to Deborah Lucas due to covid-19 precautionary measures. Deborah signed the report, and emailed the report LPA Martinez.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200619123758

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2020 Section Cited HSC 1569.312(a)(e)	1 2 3 4 5 6 7	§1569.312 Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision...(e) Monitoring the activities of the	1 2 3 4 5 6 7	Administrator has conducted a training on wandering. In addition, the facility now has additional door alarms at main entrance, Yosemite, Central Valley, Napa, Carmel.
	8 9 10 11 12 13 14	residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met by: Based on observation, file review, interviews: The licensee did not ensure to provide care and supervision to R1. As a result. R1 successfully left the facility unaccompanied by care staff. This posed and immediate health and safety risk to R1.	8 9 10 11 12 13 14	Administrator will email training materials by PCC Date 11/02/2020.
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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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

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