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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:41:59 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
07/28/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210728100440
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: DATE:
08/13/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Theresa Pettapiece, Executive DirectorTIME COMPLETED:
12:33 PM
ALLEGATION(S):
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Facility does not have the necessary hygine supplies to provide personal care services to residents.
Facility does not have a 30 day supply of PPE.
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 08/03/2021.

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

It was alleged that the facility does not have the necessary hygine supplies to provide personal care services to residents and facility does not have a 30 day supply of PPE.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 5
Control Number 27-AS-20210728100440
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 observed sufficient PPE supply in locked closet located in the Carmel Community. LPA observed in the medication room additional masks and gloves. On 8/3/2021, LPAs Garcia and Martinez conducted the initial Annual/ Inspection Control where they observed the supply room stocked with residents incontinence supplies and additional janitorial supplies such as gloves and paper products. Records reviewed show receipts for Incontinent care supplies and receipts for PPE supplies ordered and delivered.

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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 5
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
07/28/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210728100440

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: DATE:
08/13/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Theresa Pettapiece, Executive DirectorTIME COMPLETED:
12:33 PM
ALLEGATION(S):
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2
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9
There is not a sufficent number of direct care staff to support each resident’s safety and health care needs.
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 8/3/2021.

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

The complaint alleges that there is not a sufficient number of direct care staff to support each resident’s safety and health care needs.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 5
Control Number 27-AS-20210728100440
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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During the facility tour, LPA observed in Carmel Community, R1 waiting approx. 20 minutes to be fed while staff was occupied with tasks for other residents. LPAs observed in Yosemite Community, staff was assisting other residents in closed room not able to oversee and supervise R3. R3 has alloping tendencies. R3 was observed setting off multiple door alarms. Licensee did not ensure oversight on R3.

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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 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 5
Control Number 27-AS-20210728100440
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 A
08/14/2021
Section Cited
CCR
87705(c)(4)
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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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Licensee will conduct a training with the staff on proceedures to ensure there is enough "direct" staff to support the needs of the residents by POC date.
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LPA observed in Carmel Community, R1 waiting approx. 20 minutes to be fed while staff was occupied with tasks for other residents. LPAs observed in Yosemite Community, staff was assisting other residents in closed room not able to oversee and supervise R3. R3 has alloping tendencies. R3 was observed setting off multiple door alarms. Licensee did not ensure oversight on R3.
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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: 08/13/2021
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: 5 of 5