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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:59:39 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: 52DATE:
11/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Theresa Pettapiece, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Manager (LPM) Stephenie Doub and Licensing Program Analyst (LPA) Arlene Garcia conducted a Case Management - Deficiencies visit to follow up on an incident that occurred at the facility. LPM and LPA met with Administrator (AD) Theresa Pettapiece and explained the reason for the visit.

On 3/17/2020, the facility submitted an incident report and SOC341 regarding an allegation of resident abuse by a staff member. On 3/16/2020 two staff witnessed staff 1 (S1) pushing Resident 1 (R1) and holding R1's wrists forcefully. The incident occurred in the common area of the facility and R1 was seen without any clothes on from the waist down. R1 also sustained bruising to both wrists and injury to left cheek.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Pettapiece and a copy of this report was provided along with appeal and confidential names list.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited

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Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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This regulation was not met as evidence by:
The licensee did not ensure that residents were accorded dignity in their relationship with staff. Based on documentaion, S1 forcefully grabbed R1 and did not treat R1 with respect and dignity. This poses an immediate risk to residents in care.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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