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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 02:25:50 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
09/29/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210929125509
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
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Teresa Pettapiece, Executive Director (ED)TIME COMPLETED:
03:34 PM
ALLEGATION(S):
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Staff did not issue a refund upon resident's death.
Staff did not provide adequate supervision of resident resulting in a fall.
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 staff did not issue a refund upon resident's death. Residents belongings were moved out 7/18/2021. Records reviewed confirm the refund was processed at facility and sent to Corporate office on 8/27/21. Final issuance of refund from Corporate office to responsibile party was not sent until 10/18/21.

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 4
Control Number 27-AS-20210929125509
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 staff did not provide adequate supervision of resident resulting in a fall. LPA and LPM toured the 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 there is not sufficient staff to provide proper supervision. Records reveal multiple unwitnessed falls. During the month of September, 6 unwitnessed falls were reported in which 3 of the falls required medical attention.

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 4
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
09/29/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210929125509

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:
12:33 PM
MET WITH:Teresa Pettapiece, Executive Director (ED)TIME COMPLETED:
03:34 PM
ALLEGATION(S):
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Staff did not release medical records on request.
Staff did not provide meal to resident.
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 staff did not release medical records on request.
LPA reviewed resident records. Based on the records reviewed, a family member of the responsible party requested for the resident’s records. Facility did not release the records to the family member. The facility released the records to the responsible party upon their request.

It was alleged staff did not provide meal to resident.

Records revealed on the narrative charting the resident was served dinner. Staff notated on resident narrative charting the resident ate only 10% and refused the remainder of the meal Staff noted the amount of liquids consumed and followed up with the resident later that day.

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: 3 of 4
Control Number 27-AS-20210929125509
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)(4) 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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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 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
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Administator will submit a letter of understanding of the regulation to the LPA by POC date.
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This requirement is not met as evidenced by:the licensee failed to issue a refund upon the residents death within 15 days.
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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 4