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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 08/16/2021
Date Signed: 08/16/2021 12:11:38 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:THERESA L PETTAPIECEFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 58DATE:
08/16/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lindsay Beckett Business Office Manager/ Resident Care Coordinator TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. This visit is to deliver a civil penalty regarding a substantiated sexual assault allegation. LPA met with Lindsay Beckett and explained the purpose of the visit.

The above allegation was substantiated, and the licensee was cited October 22,2020 for violating California Code of Regulations (CCR) Title 22, § 87464(f)(1) for failure to provide care and supervision.

The investigation revealed resident 2 (R2) had a history of physical and sexual behaviors towards other residents and staff; however, the facility did not have a plan in place to address R2’s physical and sexual behaviors. On June 14, 2020, resident 1 (R1) was sexually assaulted by R2. R2 pulled R1’s pants down and ripped R1’s briefs off where R2 then proceeded to put R2 hand on R1’s genitalia.

The June 14, 2020 sexual incident was observed by staff 1 (S1), and S1 separated R2 from R1 at the time of the incident. S1 completed an end of shift note indicating R2 was touching R1 inappropriately. A formal complaint was made to Community Care Licensing on June 18, 2020. Moreover, during the investigation, the Department contacted the local Police Department twice; both times the Police Department stated the facility did not notify the police of the incident. It was learned the facility administrator did not send a copy of the SOC 341, Elder Abuse Report, to the local Police Department because the administrator was not aware it was a requirement.

The facility administrator also stated during an interview, “that since both residents have dementia law enforcement would not be able to do anything.” However, internal facility policy 7.46, a sexual assault is considered a crime and must be reported to local law enforcement. 809 CONT.>>>>>>>>>>>>>>>>>>>>>>>>>>>>

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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 2
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: 08/16/2021
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The facility administrator also stated during an interview, “that since both residents have dementia law enforcement would not be able to do anything.” However, internal facility policy 7.46, a sexual assault is considered a crime and must be reported to local law enforcement.

Facility narrative notes and end of shift notes dated June 10, 2020, June 12, 2020, and June 13, 2020 state that days prior to the sexual assault R2 was agitated and violent. In addition, prior to the June 14, 2020 sexual assault, R2 was found on two separate occasions pulling off R1’s blankets. It was learned R2 was redirected, however there was no safety plan in place preventing R2 from entering R1’s room.

Based on observations, interviews, and record reviews, the licensee did not provide care and supervision to R1 and R2. The lack of care and supervision resulted in R1 sustaining a sexual assault by R2. Moreover, the facility did not ensure to follow reporting requirements as 7.46 "physical assault and/or sexual assault are considered crimes and must be reported to the local law enforcement agency.” Additionally, 87211 (a) (b) Reporting Requirements: any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). As a result, the licensee neglected to protect R1 from R2.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code section 15610.63 defines physical abuse as Rape PC 261 and PC 286. The licensee failed to protect the personal rights of the resident in care. R1’s rights were violated when R1 was sexually assaulted at the facility by R2. Today, August 16, 2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49, in the amount of $10,000.



A copy of the LIC 421D was given to and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2