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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/15/2021
Date Signed: 12/15/2021 01:36:54 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
10/06/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20211006105513
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: 44DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa Pettapiece, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not ensure resident was fed.
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 staff did not ensure resident was fed.
Based on records reviewed, R1 had multiple changes in medication orders and a change in diet orders. LPA interviewed 2 staff that provided care to R1. Both staff interviewed stated R1 did not show any change in appetite. Staff stated R1 was fed a specific diet and hospice ordered a change in the diet. Staff stated when R1 didn’t like the texture of the diet, the staff had the alternative to thicken the diet and R1 would consume the meal. During a facility tour, LPA observed various alternatives to support the resident’s diet. LPA interviewed 4 staff in which all 4 staff stated if any resident denied any meal they would document on the residents charts. LPA interviewed 8 residents of which 5 residents stated they were happy with the meals provided. The remaining 3 residents interviewed were not reliable historians. Records reviewed show that R1 did not deny any meals. Interviews conducted confirm the resident was fed and offered alternatives. R1 is on Hospice care. Records indicate R1’s weight loss was documented during the monthly weighing and both Hospice and the residents responsible party was made aware. It is unclear if the changes in medication or diet contributed to the resident’s weight loss.
Therefore, the allegation staff did not ensure resident was fed 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.
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: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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
10/06/2021 and conducted by Evaluator Arlene D Garcia
COMPLAINT CONTROL NUMBER: 27-AS-20211006105513

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: 44DATE:
12/15/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa Pettapiece, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident has fallen while in care.
Resident pushed another resident while in care.
Care and supervision is not provided due to inadequate staffing
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 has fallen while in care.
Based on records reviewed, R1 fall care plan states R1 requires 1 person total assist or wheelchair excort to and from activities, meals, etc. Incident report documents R1 sustained a fall walking from Yosemite community to the Napa community.
Therefore, the allegation that the resident has fallen while in care is substantiated.
It was alleged that the resident pushed another resident while in care.
Based on interviews conducted, R2 pushed R1 from behind resulting in R1 sustaining injury and needing medical treatment. R2 admitted to pushing stating the reason for R2s action was that personal belongings were being removed with out R2’s permission. Record reviewed of R2’s Needs and Service plan shows a goal for resident to have a sense of security in the community. CCTV footage shows R2 pushing R1 from behind.
Therefore, the allegation that the resident pushed another resident while in care.is substantiate.
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: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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-20211006105513
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: 12/15/2021
NARRATIVE
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It was alleged that care and supervision is not provided due to lack of staffing.

Based on interviews conducted, LPA interviewed 10 staff. Of the 10 staff interviewed, 7 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. Records of staffing schedules and timecards of hours worked reveal 1 caregiver is scheduled for each community and 1 Medtech is scheduled for the entire facility on a regular basis. Staff are expected to oversee a community that has between 10-13 residents. Records reviewed show that 50% of residents in each community, with the exception of Monterey, require a 1 person assist with needs varying from toileting, bathing, feeding, transfers, or ambulation. Staff reported they are not able to supervise the residents when they are supporting residents in their rooms with services. Staff reported cases where they have had to place the residents in front of the television in order to keep the resident occupied when the staff were assisting other residents. Interviews confirmed residents are having to wait for assistance if a Medtech or floater is not available.

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: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20211006105513
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: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited
CCR
87463(d)
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87463 (d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: The resident (R-1) was assessed as a fall risk as notated on R1’s Needs and Service Plan/ Fall Risk Plan. R1 sustained a fall needing medical treatment. This poses an immediate health, safety, or personal rights risk to residents in care.
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Facility Administrator will develop a plan to ensure that the staffing is trained on the resident's care plan and the plan is followed Also, care staff are properly trained to perform their basis duties to meet the needs of residents. A written Plan of Correction detailing how the facility will implement an adequate procedure to assess and meet the resident's needs to be submitted by POC date.
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Based on records reviewed, R1 has a fall plan that states R1 requires 1 person total assist or wheelchair escort to and from activities, meals, etc. R1 sustained a fall walking from Yosemite community to the Napa community.
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Under Appeal
Type A
12/16/2021
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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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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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: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211006105513
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: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2021
Section Cited
CCR
87705(b)(2)
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87705(b)(2) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of
operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors
such as wandering, aggressive behavior and ingestion of toxic materials.This requirement was not met as evidenced by R1 was pushed from behind by R2 sustaining injury which required
medical attention.

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AD will train staff on Safety measures to address aggressive behavior and provide LPA with agenda and scheduled training date by POC. AD will provide a sign off of training by all staff once training has been conducted.
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Based on records reviewed, R2 admitted to pushing R1 from behind. Record reviewed of R2’s Needs and Service plan shows a goal for resident to have a sense of security in the community. CCTV footage shows R2 pushing R1 which caused R1 to sustain injuries. This poses an potential 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: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5