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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/27/2021
Date Signed: 12/27/2021 01:46:13 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
11/01/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211101160116
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: 42DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Several residents have rashes.
Resident has lice.
Resident playing with own feces at common dining table.
Unexplained falls
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Avelina Martinez and Maja Jensen arrived at the facility unannounced on 12/27/2021 at 11:15 am to deliver complaint findings, LPA met with Theresa Pettapiece and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility records. Based on interviews and observation, It was learned twenty-one residents residing in the shared communities of Carmel and Central Valley had developed an onset of rashes. Facility documentation states the first recorded rash was on January 21, 2021. Furthermore, two residents were diagnosed with scabies and all 21 residents were treated for Scabies. Resident 23 (R23) was diagnosed with Scabies on October 4, 2021 and Resident 1 (R1) was diagnosed with Scabies on November 16, 2021. Pacifica Senior Living Modesto facility began treating Central Valley and Carmel residents after the November 16, 2021 confirmed Scabies case. Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 9
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
11/01/2021 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20211101160116

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:
12/27/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Lack of kitchen staff.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Avelina Martinez and Maja Jensen arrived at the facility unannounced on 12/27/2021 at 11:30 am to deliver complaint findings, LPA met with Theresa Pettapiece and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility records. Based on interviews and document review, it was determined there was not preponderance to substantiated the above mentioned allegation. LPA Martinez was provided facility kitchen staff schedules. The schedules indicated the facility had kitchen staff scheduled to work in November of 2021. The facility has hired additional kitchen staff.

Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was given to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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 9
Control Number 27-AS-20211101160116
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: 12/27/2021
NARRATIVE
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According to Pacifica Senior Living Modesto Infection Control-12 Scabies policy, " An outbreak of scabies is defined as one confirmed case and two suspected cases of residents exhibiting signs of scabies.... Most common symptoms of scabies are severe itching, especially at night, and a pimple-like itchy...scabies rash. Tiny raised burrow lines are sometimes seen on the skin caused by the scabies tunneling just beneath the surfaces." Nine out of twenty-one residents showed severe signs of Scabies. The rash symptoms ranged from the following: red elevated bumps; full body rashes; rashes on arms, back; torso chest; abdomen; skin tears from scratching; redness in between buttocks; not sleeping during the night, and restless and walking in the middle of night; and isolation due to scabies and rash.

Pacifica Senior Living Modesto facility failed to recognize residents residing in the shared communities of Central Valley and Carmel were exhibiting Scabies symptoms and failed to implement their internal Infection Control-Scabies policy in a timely manner. Additionally, Pacifica Senior Living Modesto Outbreak Management policy 8.14 states, " The community must take immediate action to contain outbreaks of infectious illness." In addition, Policy 7.116 Resident Illness and outbreak response states, " residents may from time to time experience temporary illnesses such as colds, flu, diarrhea or general malaise. When it appears that a resident is experiencing a temporary illness: follow universal precautions... outbreaks: some illnesses are contagious and may spread to other residents and staff within the community. In order to minimize an outbreak potential, if it is determined that a resident's illness is contagious promptly recognize a developing outbreak by requesting residents and staff to report a sudden onset of symptoms." Due to Pacifica Senior Living Modesto facility’s lack of implementing infection control policies, the spread of rashes/Scabies reached the level of a full outbreak within the two communities. The facility also did not implement a safe and healthful living accommodations and services to residents in care.

Moreover, it was learned resident 9 (R9) was diagnosed with head lice on October 28, 2021 and received head lice treatment on this day. R9’s hair and scalp were inspected for lice on November 5, 2021, and it was noted R9 continued to have lice. R9 was treated for head lice on this day and was cleared on November 10, 2021. Resident 10 (R10) was covered in feces and sitting at a common dining table during dinner on October 31, 2021 at 5:00 PM. R10 was sharing a dining table with resident 11 (R11). During this time, R11's family was visiting and observed R10 had feces on his hands. The feces was also smeared on the dining table.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
NARRATIVE
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Per interviews R10 was moved to another table, and R10 was cleaned up after family informed facility staff. As a result, facility staff failed to recognize R10 had feces on his hands; and did not keep R10 clean and dry; and failed to provide adequate incontinent care and supervision. Additionally, the facility did not ensure R11 was provided a safe, healthful, and comfortable accommodations, furnishings, and equipment.

On June 6, 2021, a medical note, stated, "R11 was unsteady on feet and needs max assist with bathing and dressing and needs extensive assist with ambulation." Per investigation interview, R11 had upper extremity tremors, limited mobility, difficulty walking alone, problems with prolonged standing, and required A forward wheel walker at all times. Other medical notes reported, fall precaution measures were implemented on October 14, 2020. It was also notated instruct patient/caregiver in fall prevention start effective date April,14 2021." R11's medical fall precautions notes included: keep pathways clear; slow position change (One person hands on assist with transfer-effective date 10/14/2020; wheelchair-effective date 10/14/2020 and walker); bed alarms start effective date was 02/06/2020; and overbed table start effective date 02/06/2020."



R11's 2021 Pacifica Senior Living Modesto facility’s needs and service plan had many discrepancies. The 2021 needs and service plan stated, "ambulation... requires 1-person total assist or wheelchair escort to and from activities, meals etc... transfers: requires stand by assist." However, on another section of the same needs and service plan, it states, " Transfers stand by assist, minimal assistance at times...Ambulation resident is becoming unsteady on his feet. He leans forward when he walks." In the safety section, it states, " falls: no." In the falling section; information that was inputted on May,15 2021 states, "Assist resident with appropriate shoes when ambulating...escort resident to meals and activities, encourage resident to be seated in areas where he/she can be easily observed by staff."

Additionally, R11's 2021 needs and service plan is not signed by the responsible party. According to Pacifica Senior Living Modesto GP-06 Service Plans policy the Resident Care Director (RCD) ensures the service plan is signed and dated by the community representative and responsible party. As a result, it is indeterminate if the responsible party was made aware of the fall precaution plan.

On May 8, 2021 R11 was found sitting on closet floor. R11 was assisted up and had a scratch on his back. A May 9, 2021 medical note states, "multiple skin bruising (dark purple) noted on left upper arm just above elbow and dorsal side of bilateral hands and wrist...unwitnessed fall-fall-skin remains intact."



Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
NARRATIVE
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Narrative Charting notes reported unwitnessed fall in the community and no complain of pain on May 15, 2021. R11 had a fall in the living room around 4 PM on August 18, 2021 and sustained tears on forehead, nose, left and right forearms. R11 had another fall on August 30, 2021 Care staff was doing routine rounds and upon entering R11's room he was found half on and half off his bed. R11 sustained a skin tear to forehead and small bump under left eye.

R11 had an unwitnessed fall on September 21, 2021; R11 was found on the floor when caregiver came down the hallway between Yosemite and Napa. R11 sustained a cut to right eye and right elbow. R11 was sent to the hospital for stitches, and R11 returned to the facility on the same day at 7:30 PM. On October 15, 2021 resident had an unobserved fall. R11 had a small bump on forehead.

Based on the information gathered throughout the investigation, it was determined the facility did not ensure R11's needs and service plan properly identified his needs/ problems, goals, fall prevention and fall intervention plans. Part of his needs and service plan indicated R11 will avoid injury from falls and would be encouraged to sit in areas where he could be easily observed. However, R11's falls were mostly unobserved and in some cases in the common resident areas of the facility. As a result, the facility did not provide adequate care and supervision and did not ensure to promote fall prevention precautions.

As a result of R11 fall incidents and sustaining serious bodily injury. The violation warrants civil penalty assessments. At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.



Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The facility Administrator agrees to: Training all staff on personal rights by POC Date 12/31/2021. Statement plan and Agenda by POC Date 12/28/2021.
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This requirement was not met as evidence by:Based on file reviews and interviews, R11 was exposed to feces during dinner, and R1's dinning table had feces on it. This posed an immediate health and safety risk to R11.
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Type A
12/28/2021
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities:In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers,
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The facility Administrator agrees to: Training all staff on personal rights and care and supervision by POC Date 12/31/2021. Statement plan and Agenda by POC Date 12/28/2021.
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qualifications, and competency to meet their needs. This requirement was not met as evidence by: Based on file reviews and interviews, R10 was not supervised and was provided care to meet his needs, as he had feces on his hand during dinner. This posed an immediate health and safety risk to R10.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
87466
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87466 Observation of the Resident :The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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The facility Administrator agrees to: Training all staff on care and supervision & fall prevention by POC Date 12/31/2021. Statement plan and Agenda by POC Date 12/28/2021.
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Based on observation and file review, R11 was not observed for changes in physical needs and as a result, R1 had multiple unexplained falls with injuries. This posed an immediate health and safety risk to R1.
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Deficiency Dismissed
Type A
12/28/2021
Section Cited
CCR
1569.312(a)(e)
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1569.3129(a)(e)Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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The facility Administrator agrees to: Training all staff on care and supervision & f all prevention by POC Date 12/31/2021. Statement plan and Agenda by POC Date 12/28/2021.
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This requirement was not met as evidenced by: Based on file review and interviews, The licensee did not ensure R9's was being cared for, as R9 had lice.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/28/2021
Section Cited
CCR
87464(f)(2)
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87464(f)(2) Basic Services: Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement was not met as evidence by: based on interviews, and records review, the..
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The facility Administrator agrees to: Training all staff on care and supervision & fall prevention & infection control by POC Date 12/31/2021. Statement plan and Agenda by POC Date 12/28/2021.
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licensee failed to provide basic services to facility residents and failed to provide a clear definitive plan to prevent the spread of rashes/Scabies and prevent residents from contracting contagious illnesses. This posed an immediate 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 27-AS-20211101160116
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: 12/27/2021
NARRATIVE
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REPEAT VIOLATIONS
  1. Violation of California Code of Regulations Section 87468.1(a)(2) was 12/28/2020. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed in the amount of $ 1,000.00 dollars.
  2. Violation of California Code of Regulations Section 87466 was 04/14/2021. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed in the amount of $ 1,000.00 dollars.

As a result of this investigation, the Department finds these allegations to be substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations and appeals rights given.

An exit interview was conducted, and a copy of report provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9