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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 08/03/2021
Date Signed: 08/03/2021 07:14:03 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: 60DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa Pettepiece, Executive Director (ED)TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia and LPA Avelina Martinez conducted an unannounced annual / Infection Control visit on this date. LPAs met with Theresa Pettepiece, Executive Director (ED)

LPAs inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining/ living room areas.

LPAs inspected 5 resident communities. LPAs observed meal service in Central Valley and Carmel Communities. Carmel has 10 residents and 1 caregiver. Staff, S1 stated that resident, R1 requires assisted feeding. LPAs observed R1 waiting approx. 20 minutes to be fed by S1. S1 served meals to 9 other residents, cleaned food service, and prepared cart to return to kitchen prior to feeding R1. LPAs observed R2 in Carmel laying in soiled sheets after being changed into new briefs. S1 stated she had recently changed R2 and R2 was supposed to come out for lunch. LPAs observed R3 who resides in Napa, walking around in Yosemite setting off multiple alarm doors. Yosemite has 10 residents and 1 caregiver. S3, caregiver for Yosemite, was in room 104 assisting two residents. LPAs observed S3 in closed room door for approx. 10 minutes. LPAs observed R3 attempting to leave thru door to front lobby where Receptionist came to door to redirect.

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

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 4
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: 08/03/2021
NARRATIVE
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809 CONT.>>>>>>>>>>>>>>>>>>

LPAs observed blinds in multiple residents rooms broken, screen in resident room broken, dirt on baseboards throughout facility, stains on walls, and electrical outlets broken. LPAs observed resident bathroom 210 and bathroom 212 with feces stains on and around toilet and dirt in the showers.

LPAs observed milk in Central Valley, Napa, and Yosemite were expired. LPAs observed frozen foods in freezer showing signs of freezer burn. Toxic cleaning chemicals were stored on top of the dish washing area. LPAs observed a container on the counter not dated. Kitchen staff stated it was tea they prepared for the residents. LPAs inspected kitchen area and storage area with incontinent care and housekeeping supplies.

LPAs inspected egress doors in all 5 communities. LPAs observed doors in Carmel and Yosemite were not reset. LPAs observed special egress control device on doors in Monterey not functioning. LPAs were able to open doors without egress door alarming. LPAs observed the keypad on outside of doors were not functioning. LPAs observed Nurse visitor opening door and walking into community.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with ED and a copy of report given via email.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2021
Section Cited

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87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Based on observation, LPAs observed R1 waiting approx. 20 minutes to be fed while staff was occupied with tasks for other residents. Licensee did not ensure oversight on R3. Staff was assisting other residents in closed room. R3 has alloping tendencies. R3 was observed setting off multiple door alarms.
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Type A
08/03/2021
Section Cited

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1569.699
Exit doors; egress-control devices of time-delay type; fences (a) When approved by the person responsible for enforcement, as described in Section 13146, exit doors in facilities classified as Group R, Division 2 facilities under the California Building Standards Code, licensed as residential care facilities for the elderly, and housing clients with Alzheimer’s disease or major neurocognitive disorder, may be equipped with approved listed special egress-control devices of the time-delay type, provided the building is protected throughout by an approved automatic sprinkler system and an approved automatic smoke-detection system. The devices shall conform to all of the following requirements:

(1) Automatic deactivation of the egress-control device upon activation of either the sprinkler system or the detection system.
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This requirement was not met by: based on observations, LPAs observed egress doors not reset in Carmel and Yosemite Communities and egress doors in Monterey communtiy not functioning.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited

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87555 General Food Service Requirements (b) The following food service requirements shall apply:(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
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This regulation is not met as evidence by; based on observations, LPAs observed expired milk, food prepared with no label or date, forzen foods with freezer burn.
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Type B
08/03/2021
Section Cited

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87303
Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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This evidence was not met by: LPAs observed blinds in multiple residents rooms broken, screens in resident rooms broken, dirt on baseboards throughout facility, stains on walls, and electrical outlets broken. LPAs observed resident bathroom 210 and bathroom 212 with feces stains on and around toilet and dirt in the showers.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4