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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 02/01/2022
Date Signed: 02/01/2022 04:39:39 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
01/28/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220128115634
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
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility did not report incident of fire to CCL
Staff did not follow protocols during fire at facility
INVESTIGATION FINDINGS:
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On 2-1-22 at 10:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegations noted above. LPA met with Administrator Theresa Pettapiece and explained the purpose of the visit. LPA interviewed Administrator, maintenance director, staff and residents in care. LPA also conducted facility observation and reviewed facility emergency disaster plan. Based on interviews and observation, it was determined that a small electrical fire occurred as a result of a faulty wire in Resident1 (R1's) room. Based on additional interviews, it was determined that this occurrence was not reported to licensing department and fire department per regulation and facility protocol.

Based on interviews, record reviews, and observation, the preponderance of evidence standard is met, therefore, these allegations are SUBSTANTIATED. Deficiencies are cited based on Title 22, Division 6, Chapter 8. An exit interview was conducted with Theresa Pettapiece and a copy of this report was left with Theresa. Appeal rights provided.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220128115634
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: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2022
Section Cited
CCR
87211(a)(3)
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Reporting requirements. (a)Each licensee shall furnish to the licensing agency such reports...including...(3) Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; ...within 24 hours...and no later than the next working day to the licensing agency.
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Licensee or designee will read regulation 87211 and submit a signed statement of understanding to LPA by POC due date.

Licensee will ensure staff training on regulation 87211 is completed. Proof of training to be submitted to LPA by POC due date.
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This requirement is not as evidenced by: Based on interview and record review, Licensee did not ensure the report of a small electrical fire in R1s room occurring on 1-21-22 to licensing agency and local fire authority. 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2