507004251-11-9-2020-27-AS-KHOS-BV8PSA-20201110103402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 11/09/2020
Date Signed: 11/09/2020 01:59:40 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
05/28/2020 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20200528111651

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: 58	DATE:	11/09/2020
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	01:41 PM

ALLEGATION(S):

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Facility failed to prevent visitor from videotaping residents and posting on social media.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation on 11/09/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation(s) with Deborah Lucas.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. The facility administrator stated, "she was unaware that a family visitor at the facility was video recording residents. Furthermore, during the video recording, resident 1 (R1), and her family members were having a private visit. It was brought to the administrator's attention after it was uploaded to a social media website.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200528111651

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: 11/09/2020

NARRATIVE

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Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted with Deborah Lucas via telephone and a copy of this report was provided to Deborah Lucas via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020

LIC9099 (FAS) - (06/04)

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