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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 06/24/2021
Date Signed: 06/28/2021 10:16:24 AM



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
03/25/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210325164357
FACILITY NAME:PACIFICA SENIOR LIVING MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 60DATE:
06/24/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director, Deborah LucasTIME COMPLETED:
11:46 AM
ALLEGATION(S):
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Facility did not request exception for resident to sleep in a recliner.
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) Deborah Lucas.

The initial 10 day Visit was conducted on 3/29/2021.

It was alleged that the facility did not request exception for resident to sleep in a recliner.
LPA observed C2 sleeps in a recliner. C2 is non-ambulatory and not on hospice. C1 is the responsible party for C2. C1 is the spouse of C2 and a resident of facility. C1 confirmed that they have requested this accommodation from the facility. Facility does not have an approved exception letter from Community Care Licensing for the use of recliners in lieu of beds. LPAs observed there are beds available in the facility for the residents, however, the residents requested to have the beds removed to allow them additional living space. C1 and C2 request to sleep in recliners.
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: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 3
Control Number 27-AS-20210325164357
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: 06/24/2021
NARRATIVE
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9099 CONT. >>>>>>>>>>>>>>>>>>>>

Based on information provided through interviews and records reviewed, the allegation was deemed SUBSTANTIATED. This agency has investigated the allegation noted and have found the allegation to be substantiated, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview conducted with ED, Deborah Lucas 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: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210325164357
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: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2021
Section Cited
CCR
87824(b)(2)
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Waivers and Exceptions
(b) The Department shall have the authority to approve the use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conducting of experimental or demonstration projects under the following circumstances:
(2) The applicant or licensee shall submit to the Department a written request for a waiver or exception, together with substantiating evidence supporting the request.
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Licensee agrees to submit a written plan of correction to LPA by 07/05/2021 on how the facility will be in compliance with regulation 87824(b)(2) at all times. ED will submit an exception request to community care licensing for the approval for the residents to sleep in recliners.
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This requirement is not met as evidenced by: Based on interviews and records review, the administrator did not ensure facility has an approved exception letter from Community Care Licensing for the use of recliners in lieu of beds. This posed a potential health and safety risk to C1 and C2.
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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: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3