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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/09/2021
Date Signed: 12/09/2021 03:20:36 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
10/04/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20211004160447
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: 45DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Teresa Pettapiece, Executive Director EDTIME COMPLETED:
01:37 PM
ALLEGATION(S):
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Facility has pests.
Facility has mold.
Facility does not properly handle facility records.
Staff member gave resident the wrong medication.
Facility does not maintain accurate resident records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Pacifica Senior Living Modesto to deliver the finding of the above allegations. LPA met with Executive Director (ED) Teresa Pettapiece.
It was alleged that the facility has pests and that the facility has mold. LPA toured the facility and did not observe pests or mold. LPA interviewed the Facility Manager and the Business Manager and both have stated they have not observed pests or mold in the facility. Records reviewed confirm facility has a regular monthly third party pest control service. Interviews conducted confirm that if the pest control observed any concerns additional contracted service would be documented and invoiced. There is no documents of additional services requested and conducted.
Therefore, the allegation that the facility has pests and that the facility has mold. Is unsubstantiated
9099 CONT. >>>>>>>>>>>>>>>>>>>>>>
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: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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-20211004160447
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: 12/09/2021
NARRATIVE
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It was alleged the facility does not properly handle facility records and the facility does not maintain accurate resident records.

LPA reviewed a random sample of 9 employee files and observed all files were complete and retained by facility. LPA reviewed a random sample of 9 resident files and observed all files were complete and retained in facility.. During tour, LPA observed facility files locked in a secure location and over 3 years of records retained

Therefore, the allegation the facility does not properly handle facility records and the facility does not maintain accurate resident records Is unsubstantiated.

It was alleged staff member gave resident the wrong medication.



File review and records reveal facility has been previous cited for incident reported regarding medication. LPA reviewed a random selection of 12 current medical records which show no concerns of wrong medication being administered. Third Party OmniCare medication audit conducted in August 2021 documents the facility in compliance. Interviews
Therefore, the allegation staff member gave resident the wrong medication is unsubstantiated.

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.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
10/04/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20211004160447

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: 45DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Teresa Pettapiece, Executive Director EDTIME COMPLETED:
01:37 PM
ALLEGATION(S):
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Facility does not have sufficient staff to meet the residents' needs.
Residents needs are not being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia 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 does not have sufficient staff to meet the residents needs and the residents needs are not being met.
Based on records reviewed confirm there are days where staff are having to monitor 2 communities due to staffing concerns. LPA interviewed 7 staff. Of the 7 staff interviewed, 5 staff reported that on a regular basis, staff are responsible to monitor 1 community and there is a floating medtech to support the caregivers if needed. Staff reported they are not able to supervise the residents when they are supporting residents in their rooms with services. Interviews revealed that there is not always a floating medtech able to assist. Residents are placed in front of the television while caregivers are assisting residents in their rooms. Residents in need of assistance are expected to wait for caregiver or medtech to be available. Some residents do not choose to wait and attempt to walk or assist themselves. During the September, records reveal there were 7 falls of which 6 were unwitnessed of which 2 residents required medical attention at the hospital.
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: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 5
Control Number 27-AS-20211004160447
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: 12/09/2021
NARRATIVE
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Residents needing incontinent care are having to wait or staff are having to place residents in front of the television as part of an activity allowing time for caregiver to assist other residents in their rooms. Caregivers are not able to witness all falls because they are completing rounds of 2 communities on opposite ends of building. Interviews revealed that caregivers will be assisting residents in one community and cannot see or hear residents in the other community. Caregivers rely on the alarms to notify them of potential elopements.

Therefore, the allegation that the facility does not have sufficient staff to meet the residents needs and the residents needs are not being met is substantiated.

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: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211004160447
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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
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.
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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. This poses an immediate health, safety, or personal rights risk to residents in care.
Based on information provided during interviews, staff are unable to provide direct supervision. Resident’s are placed in front of the television in order for caregivers to provide care. Residents are having to wait for incontinent care until a floating medtech or other staff member is available.
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Type A
12/10/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements -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. … agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, … 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 requirement was not met as evidence by: Based on Interviews and records reviewed, staff are relying on alarms for potential elopements. Staff are unable to witness falls. Staff are monitoring more than one community and unable to provide residents with care needed in a timely manner. This poses an immediate health, safety, or personal rights 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5