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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 02/01/2022
Date Signed: 02/01/2022 04:51:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 43DATE:
02/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Theresa PettapieceTIME COMPLETED:
04:55 PM
NARRATIVE
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On 2-1-22 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit based on a previous visit for complaint #27-AS-20220128115634. LPA met with Administrator Theresa Pettapiece and explained the purpose of the visit. LPA toured facility with Administrator, reviewed emergency disaster plan, fire drill log, training records, plan of operation, and tested fire alarm system. LPA also interviewed Administrator and Maintenance Director. Based on record review, interviews, and facility observation it was determined that the fire alarm system is not functioning properly per specifications of communication panel currently in place. Upon testing alarm, no signal was heard to alert residents, staff, and visitors of potential fire danger and alarm system did not alert the local fire department accordingly.

Upon additional record review, it was determined that fire drills were not being conducted quarterly per regulatory requirements.

Deficiencies are cited today based on Title 22, division 6, chapter 8.. An immediate civil penalty in the amount of $500 is assessed in addition to citation issued.

An exit interview was conducted with Theresa Pettapiece and a copy of this notice of left with Theresa. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2022
Section Cited

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Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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Based on LPA observation, licensee did not ensure fire alarm system was functioning properly. Alarm was not funtioning to alert residents, staff, and visitors of potential fire danger. This poses an immediate health and safety risk to residents in care. An immediate civil penalty of $500 is assessed in addition to citiation issued.
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Licensee will ensure firewatch service is in place to meet the safety needs of all residents until fire system is appropriately functioning. Licensee to submit copy of firewatch agreeement to LPA by POC due date.

Licensee to maintain firewatch log and submit copy of log to LPA by POC due date.
Type B
02/11/2022
Section Cited

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Care of Persons with Dementia. (k) The following initial and continuing requirements must be met for the licensee to utilize delayed eggress devices on exterior doors or perimeter fence gates:(3)Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement is not met as evidenced bv: Based on record review and interview, fire drills were not conducted quarterly per regulations. This 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2022
LIC809 (FAS) - (06/04)
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