507004251-10-12-2021-27-AS-AMAZ-C7QLU8-20211012090329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 10/12/2021
Date Signed: 10/12/2021 09:03:39 AM

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 MODESTO		FACILITY NUMBER:	507004251
ADMINISTRATOR:	THERESA L PETTAPIECE		FACILITY TYPE:	740
ADDRESS:	2325 ST PAUL'S WAY		TELEPHONE:	(209) 491-0800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS: 59	DATE:	10/12/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Rashmika Sharma		TIME COMPLETED:	09:15 AM

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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced to conduct a case management visit. This visit is to deliver a civil penalty regarding lack of care and supervision. LPA Avelina Martinez met with Rashmika Sharma and explained the purpose of the visit.

On April 14 2021, the Department completed a case management for the purpose of following up on deficiencies found during a complaint investigation reference # 27-AS-20201019113049.

The licensee was cited for violating California Code of Regulations (CCR) Title 22, §. 87465 (a) Incidental Medical and Dental Care for not receiving timely medical attention. The licensee was also cited for CCR Title 22, § 87466 Observation of the Resident for not ensuring to observe R1’s health condition changes and reporting the health condition changes to R1’s authorized representative in a timely manner.

The investigation revealed that on October 15, 2020, R1’s unwitnessed fall occurred at the back patio outside of the Carmel Community. The fall occurred at the PM shift between 2 PM and 10 PM. Facility notes reported R1 sustained a skin tear to left cheek; a skin tear to the right side of hand; and a skin tear to his left thumb. At the time of, the October 15, 2020 fall incident, a med-tech called the facility’s Resident Care Director (RCD). The RCD conducted a phone assessment with the Med-tech, and the RCD determined not to send R1 to the hospital. It was reported it took four caregivers to return R1 to his bedroom after the October 15, 2020 fall. One caregiver reported R1 needed to be sent out to the hospital.

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SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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

LIC809 (FAS) - (06/04)

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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: 10/12/2021

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On October 16, 2020, while R1 was sitting on the recliner, a care staff observed a skin abrasion to his right top hand and purple discoloration to R1’s right eye with an abrasion. A med-tech provided first aid; however, R1 was not sent to the hospital on this day. On October 17, 2020 at approximately 2:30 PM, a Med-Tech reported R1 complained of pain and could not stand. Additionally, R1 yelled out in pain while being assisted to a sitting position. On October 17, 2020. R1 was sent out to the hospital. Hospital notes indicate R1 sustained the following injuries left femoral neck fracture-hip fracture and elbow injury. In addition, R1 required a hip hemiarthroplasty, which was conducted on October 18, 2020. According to Mayo Clinic, signs and symptoms of a hip fracture include inability to get up from a fall or to walk; severe pain in your hip or groin; and Inability to put weight on your leg on the side of your injured hip. Additionally, according to Mayo Clinic, most hip fractures occur in one of two locations on the long bone that extends from your pelvis to your knee (femur): The femoral neck: this area is situated in the upper portion of your femur, just below the ball part (femoral head) of the ball-and-socket joint. The intertrochanteric region: this region is a little farther down from the hip joint, in the portion of your upper femur that juts outward.

Based on documents and interviews, the investigation revealed Pacifica Senior Living Modesto facility did not seek medical attention in a timely manner. Pacifica Senior Living Modesto’s Clinical 11 fall response procedures policy states, "If the resident had trauma resulting in deformity, exhibits any change in level of consciousness, or received obvious head or significant trauma, the Resident Care Director or Personal Care Assistants will summon emergency medical services (Call 911)." The facility did not adhere to its policies and procedures.

At the time of the complaint visit on April 14, 2021, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, October 12, 2021, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000.

A copy of the LIC 421D was given to Rashmika Sharma and originals were signed on file.

An exit interview was conducted. A copy of the report was issued. Appeal Rights provided. Rashmika Sharma signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC809 (FAS) - (06/04)

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