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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 03:28:29 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
09/23/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210923142254
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:
10:16 AM
MET WITH:Teresa Pettapiece,Executive Director (ED) .TIME COMPLETED:
11:27 AM
ALLEGATION(S):
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Resident eloped from facility.
Facility is not taking necessary precautions to prevent the spread of COVID-19.
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 Resident eloped from facility.
Based on interviews conducted the resident was in supervision at all times. The resident attempted to leave the building through facility doors that lead into the kitchen where a staff member was working. Staff member observed resident and proceeded to supervise the resident until the caregiver was able to assist getting the resident to return back to the resident’s community.
Therefore, the allegation the resident eloped from the facility is deemed 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
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
09/23/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20210923142254

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:
12/09/2021
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Teresa Pettapiece.,Executive Director (ED) TIME COMPLETED:
11:27 AM
ALLEGATION(S):
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Residents are falling due to lack of staff.
Facility is not reporting Covid-19 cases to CCLD.
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 residents are falling due to lack of staff.
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. Staff stated they are not always able to observe all the unwitnessed falls that are occurring. 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.
Therefore, the allegation that residents are falling due to lack of staff is substantiated.

9099C. >>>>>>>>>>>>>>>>>>>>>>>>
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: 2 of 5
Control Number 27-AS-20210923142254
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 that the facility is not reporting Covid-19 cases to CCLD.
Based on interviews conducted, there were two staff members that tested positive to Covid-19. Although, the staff were not working when they tested positive, they are employees of the facility and potentially have access to the facility and the residents in care. Facility personal conducted the Covid-19 testing and observed both positive results. The positive results were not reported to CCLD or LHD.
Therefore, the allegation that the facility is not reporting Covid 19 positive cases to CCLD is substantiate.
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: 3 of 5
Control Number 27-AS-20210923142254
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 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
12/19/2021
Section Cited
CCR
87211(a)(2)
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87211 (a)(2) Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Administrator shall review reporting requirements under section cited and provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations regarding reporting requirements and agrees to report as required in the future.
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This requirement is not met as evidenced by: Administrator had knowledge of two staff being covid positive. The licensee did not ensure the facility reported the covid positive cases to Public Health or CCL.
This violation poses a potential health, and safety 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: 4 of 5
Control Number 27-AS-20210923142254
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 that the facility is not taking necessary precautions to prevent the spread of COVID-19.
Based on records reviewed, the facility follows their approved mitigation plan. Documents confirm proper screening prior to entry is conducted and any staff that have tested positive or show signs of symptoms are not reporting to work. Interviews conducted confirm the staff have access to rapid testing and weekly surveillance testing is completed. When staff test positive, the staff are required to quarantine to stay at home for 10 days prior to returning to work.
Therefore, the allegation the facility is not taking necessary precautions to prevent the spread of Covid-19 is deemed 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: 5 of 5