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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 11/08/2021
Date Signed: 11/09/2021 02:23:15 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
08/27/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210827150855
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: DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa Pettapiece, Executive Director (ED)TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility not disposing medication appropriately.
Facility failed to provide adequate laundry service.
Licensee does not have sufficient staff to meet the needs of the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia and Licensing Program Manager (LPM Stephenie Doub made an unannounced visit to Pacifica Senior Living Modesto to deliver the finding of the above allegations. LPAs met with Executive Director (ED) Teresa Pettapiece.

It was alleged that the facility was not disposing medication appropriately.
Based on records reviewed and interviews conducted, expired medications were disposed that were not documented on the centrally stored medication and destruction record.

Interviews conducted confirm facility was preparing for medication audit to be conducted by a third party vendor in August 2021. During the preparation, facility completed an internal audit and staff disposed of all expired medications. Records show an expired medication that was not being administered to a resident (R2) was documented as start date of 7/23/21 with an expiration date of 8/1/21. LPA observed no documentation of the resident’s medication being disposed. LPA observed no expired medications in the Medical storage area.

9099 CONT. >>>>>>>>>>>>>>>>>>>>>>>>>
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20210827150855
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: 11/08/2021
NARRATIVE
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9099 CONT. >>>>>>>>>>>>>>>>>>

It was alleged that the facility failed to provide adequate laundry service.
LPA toured the facility and observed laundry that was previously serviced the Monterey community was now being serviced in the main laundry room because the washer broke down. Interviews conducted confirm the housekeeper was out of the community for an extended period of time. Although the facility put a plan in place, staff reported that residents did not have their own clean clothes to wear and alternative clean clothing was provided to the residents.

It was alleged that the licensee does not have sufficient staff to meet the needs of the residents.
LPA toured facility. The facility has 5 communities each community with an average of 10-13 residents at one time. Based on records reviewed, during the month of September there was no Medtech scheduled on Sundays for the Day shift and Night shift and there are no more than 4 staff scheduled for PM shift on weekends and weekdays. On three days during month there was no Medtech scheduled for PM shift and on separate days during month only 3 staff scheduled for PM shift for entire facility. Staff interviews confirmed staff are unable to provide residents needs for incontinent care. Staff are unable to provide supervision. Records reveal multiple unwitnessed falls.

Based on information provided through interviews and records reviewed, these allegations are deemed SUBSTANTIATED. This agency has investigated the allegations noted and have found the allegations to be substantiated, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiencies was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with ED, Teresa Pettapiece and a copy of this report was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210827150855
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
87705(c)(4)
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87705 (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.
This requirement is not met as evidenced by:the licensee did not provide adequate number of direct care to residents. This poses an immediate health, safety, or personal rights risk to residents in care.
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Administration will need to provide a staffing plan to ensure adequate direct staff are available to support the needs of the residents by POC date.
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This requirement is not met as evidenced by:the licensee did not provide adequate number of direct care to residents.Based on information provided during interviews, staff are unable to provide resdients needs for incontinient care. Staff are unable to provide supervision. Records reveal multiple unwitnessed falls. This poses an immediate health, safety, or personal rights risk to residents in care.
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Type B
11/18/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Administration will need to provide a staffing plan to ensure adequate staff is sufficient to provide the necessary services by POC date.
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This requireent was not met as evidence by: Based on Interviews, staff reported that residents did not have their own clean clothes to wear and alternative clean clothing was provided to the residents.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210827150855
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: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2021
Section Cited
CCR
87465(i)
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87465 (i) Incidental Medical and Dental Care
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
(1) Name of the resident.
(2) The prescription number and the name of the pharmacy.
(3) The drug name, strength and quantity destroyed.
(4) The date of destruction.
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Administrator will conduct a training with all staff the handle medications on proper medication disposal proceedures. Administrator will submit agenda and training sign off to LPA by POC date.
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This requirement was not met by evidence by: Based on records reviewed and interviews conducted, expired medications were disposed that were not documented on the centrally stored medication and destruction record.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 4 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
08/27/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210827150855

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: DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa Pettapiece, Executive Director (ED)TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Newly hired staff are not receiving health screening physicals.
Missing medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia and Licensing Program Manager (LPM) Stephenie Doub made an unannounced visit to Pacifica Senior Living Modesto to deliver the finding of the above allegations. LPAs met with Executive Director (ED) Teresa Pettapiece.
It was alleged that newly hired staff are not receiving health screening physicals.
LPA reviewed staff records. Records revealed 4 of 4 recently hired staff in last 6 months have all completed proper health screen and TB testing.
It was alleged that there are missing medications.
It was alleged the missing medications were specifically referencing pain medication and narcotics. LPA reviewed a random sampling, and those medications were accounted for. LPA did not observe any missing medications. LPA reviewed random sample of residents’ LIC 622 Centrally Stored Medication and Destruction Records, physician’s orders, Controlled Substance logs, and resident MAR reports. LPA reviewed Omnicare Audit on Medication Storage/Handling/Administration.

Based on information provided through interviews and records reviewed, these allegations are deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 5 of 5