507004251-3-3-2022-27-AS-AMAZ-CC6T4J-20220303132400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 03/03/2022
Date Signed: 03/03/2022 01:24:32 PM

Document Has Been Signed on 03/03/2022 01:24 PM - It Cannot Be Edited

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 MODESTO		FACILITY NUMBER:	507004251
ADMINISTRATOR:	THERESA L PETTAPIECE		FACILITY TYPE:	740
ADDRESS:	2325 ST PAUL'S WAY		TELEPHONE:	(209) 491-0800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS:	DATE:	03/03/2022
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Theresa Pettapiece, Cassandra Bradford, Carl Kneple		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On March 3, 2022 an office visit was conducted virtually, via Microsoft Teams. Present in the meeting were Regional Manager (RM) Krystall Moore, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Manager Stephanie Doub, Licensing Program Analyst Avelina Martinez. Regional Manager Brenda White, Licensing Program Manager Sergiy Pidgimy, Licensing Program Analyst Lady Cabrera. DSS Auditors Jacqueline Juarez and Banahene Benjain. Facility representatives include: Administrator Theresa Pettapiece, Director of Operation Cassondra Bradford, Director of Quality Assurance Marlene Nelson and Counsel Joel Goldman,. RM Moore explained the purpose of the meeting. LPA Martinez discussed the visit on March 3, 2022 and citations issued., The purpose of this Microsoft virtual office visit is to discuss the facilities continued non-compliance with Title 22 Regulations and Health and Safety Code. The facility has shown the inability to remedy the Department's concerns and citations. A Non-Compliance Conference was held on January 07, 2020 to discuss issues and concerns, but the facility continues to struggle to stay in compliance. The facility was provided with Technical Support Program (TSP) and successfully completed the engagement. And as of December 23, 2021, after the Accusation was filed, the facility continues to be cited. A Citations= 8 · 87465 Incidental Medical and Dental Care · 87466 Observation of the Resident · 87468.1 Personal Rights of Residents · 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities · 87466 Observation of the Resident Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 03/03/2022

NARRATIVE

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·87464 Basic Services
· 87464 Basic Services
· 87203 Fire Clearance

B Citations= 2
· Reporting Requirements
· Care of Persons with Dementia

Due to the abovementioned concerns and deficiencies, the Department has conducted this meeting to address the ongoing concerns. In addition to, discussing Pacifica Senior Living Modesto plan to correct the Department's concerns. The Department is also requesting Pacifica Senior Living Modesto to submit a written plan on the course of action that will be taken to correct the concerns, and how the Licensee will provide oversight on Pacifica Senior Living Modesto management staff and care staff.

The facility has stated they will do the following to achieve continued and substantial compliance:
· Will have a Regional Nurse present in the facility every other week to conduct medication audit and will provide copies of the audit no later than 5 days to DSS..
· Corporate staff will be present in the community to provide oversight
· Special Incident Reports to be submitted as required
· Reappraisals will be conducted as residents’ conditions changed by Resident Care Director and facility will follow up with appropriate steps
· Facility will not retain residents that need a higher level of care ( will relocate, and or provide 1:1 as needed)
· Facility will update the Fall Prevention Plan
· Facility will update the Plan of Operation and provide to the DSS for review and approval
· Facility will ensure timely medical care for all residents
· Facility has communication logs and will check residents conditions at all shift changes ( to include NOC and weekend shifts)
Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 03/03/2022

NARRATIVE

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Requested Documents (All requested documents are due by March 14, 2022. If you are unable to submit documents by March 14, 2022, please contact the Department)

· Submit updated plan of operation, which included new updated policies (revised plan of operation will need to be approved by the Department)
· Submit financial records to the Audit Section by March 14, 2022. (Please refer to the engagement letter that was provide to your facility.)

CCLD will do:
CCLD will increase monitoring.

Per California Code of Regulations (CCRs) - Title 22, no deficiencies are being cited during this visit. An exit interview was conducted with Theresa Pettapiece via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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