507004251-8-13-2021-27-AS-SDOB-C5ZTJF-20210818144615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:19:41 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
02/16/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210216131027

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: 60	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Theresa Pettapiece, Executive Director		TIME COMPLETED:	12:27 PM

ALLEGATION(S):

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Residents are not receiving proper first aid care.
Residents are not being provided wound care for their pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced complaint visit on this day for the purpose of concluding a complaint investigation. On this day LPA met with Executive Director, Theresa Pettapiece explained the reason for the visit.

The initial 10-day visit was conducted on 02/25/2021.

Through the course of the investigation, LPA conducted interviews and reviewed staff and resident records.

It was alleged that the residents are not receiving proper first aid care and residents are not being provided wound care for their pressure injuries.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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 6

Control Number 27-AS-20210216131027

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: 08/13/2021

NARRATIVE

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LPA conducted interviews with staff that confirm they have a full understanding of how to administer first aid. Records reviewed document all staff have certificated First Aid training. LPA conducted interviews where staff were able to explain the proper process on observing and communicating concerns on wounds of residents. Records reviewed show the narratives of the concerns the staff have with any resident wounds, communication to the RP of the residents with concerns, the communication to the resident physicians, and the followed instructions from the Residents physicians.

Due to this uncertainty, the allegation that residents are not receiving proper first aid care and residents are not being provided wound care for their pressure injuries were deemed unsubstantiated.

Based on information provided through interviews and documentation, it was unclear that residents are not receiving proper first aid care and residents are not being provided wound care for their pressure injuries. Therefore, the allegation was deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

No deficiencies cited. An exit interview was conducted with Executive Director, Theresa Pettapiece

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
02/16/2021 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210216131027

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: 60	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Theresa Pettapiece, Executive Director		TIME COMPLETED:	12:27 PM

ALLEGATION(S):

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Facility failed to provide adequate laundry service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced complaint visit on this day for the purpose of concluding a complaint investigation. On this day LPA met with Executive Director, Theresa Pettapiece explained the reason for the visit.

The initial 10-day visit was conducted on 2/25/2021.

Through the course of the investigation, LPA conducted interviews and reviewed staff and resident records.

9099 CONT. >>>>>>>>>>>>>>>>>>>>>>>>.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 27-AS-20210216131027

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: 08/13/2021

NARRATIVE

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The complaint alleges that facility failed to provide adequate laundry service. Interviews with the staff and records reviewed provided consistent information and evidence that the allegations are valid. The previous Executive Director acknowledged the dryer was not working and purchased a brand new one.

Licensing has determined the above allegations are (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and report provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 27-AS-20210216131027

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: 08/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/23/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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 2 3 4 5 6 7	Licensee corrected. Licensee provided proof that a new dryer was purchased and installed. LPA observed new functioning dryr.
	8 9 10 11 12 13 14	This regulation was not met bu evidence by: Interviews with the staff and records reviewed provided consistent information and evidence that the allegations are valid. The previous Executive Director acknowledged the dryer was not working and purchased a brand new one.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6