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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/11/2021
Date Signed: 06/11/2021 01:57:02 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
10/01/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201001105247
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: 59DATE:
06/11/2021
UNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Deborah LucasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents are being administered the wrong medication.
Resident's medications are being discarded inappropriately in the garbage bin.
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INVESTIGATION FINDINGS:
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On 06/11/2021 at 1:26 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez identified herself and discussed the purpose of the visit and the elements of the allegations with Deborah Lucas.

LPA Martinez returned to the facility to deliver complaint findings and citations that were not delivered at the 05/27/2021 complaint visit. The above citations were erroneously not added to 05/27/2021 9099 D report. The above substantiated allegations were reviewed with Deborah Lucas at today's visit. The deficiencies can be found on LIC 9099-D, per Title 22 Regulations and appeals rights given.

A exit interview was conducted. A copy of this report was given to Deborah Lucas.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20201001105247
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: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/14/2021
Section Cited
CCR
87465(a)(i)
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87465(a)(i) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility...Prescription medications which are not...nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record...Shall be destroyed in the facility by the facility
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Facility administrator has conducted incidental and dental care training on 01/08/2021. The administrator agrees to provide all departments with training on mishandled medications by POC 6/25/2021. Administrator will email training agenda by 06/14/2021 to LPA.
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administrator and one other adult who is not a resident. This requirement is not met as evidenced by: Based on interviews and record review, the administrator did not ensure that medications were being properly destroyed, as medications were found in the garbage. This posed an immediate health and safety risk to residents in care.
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Request Denied
Type A
06/14/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a)(5). A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Facility administrator has conducted incidental and dental care training on 01/08/2021. The administrator agrees to provide all departments with training on mishandled medications by POC 6/25/2021. Administrator will email training agenda by 06/14/2021 to LPA.
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This requirement is not met as evidenced by: Based on interviews and records review, the administrator did not ensure resident 1 (R1) was administered the correct medication. This posed an immediate health and safety risk to R1.
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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: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2