507004251-3-11-2022-27-AS-AMAZ-CCERBY-20220311115332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:53:42 AM

Document Has Been Signed on 03/11/2022 11:53 AM - 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: 40	DATE:	03/11/2022
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Lindsay Beckett		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez identified herself and discussed the purpose of today's visit with Lindsay Beckett.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation 27-AS-20211103130829.

It was learned resident 1 (R1) did not have a fall prevention plan in place and was considered to be a fall risk. Per facility physician communication note, R1 was a fall risk and an inflatable lap buddy was requested. On a 12/10/2020 facility note, it was stated, "received order for inflatable lap buddy." However, R1's Needs and Service did not include a fall prevention plan. In addition, the Needs and Service Plan did not included inflatable lap buddy.

During interviews, witness 1 (W1) reported during a September 26, 2021 facility visit, R1 did not have the inflatable lap buddy on his wheelchair. LPA Martinez also requested lap buddy documentation and Needs and Service Plan from the Resident Care Director (RCD), and was informed there was no documentation for the lap buddy, and it was unknown if R1 had a lap buddy.

It was noted R1 sustained seven fall from the December 10, 2020 to September 25, 2021 per Pacifica Senior Living Modesto Fall Management Policy 7.69 a fall is defined as such, " A fall is defined as any drop, collapse or tumble." Facility notes indicate R1 slid out of his wheelchair on December 17 , 2020. On January 19, 2021 it was noted R1 slid out his wheelchair and dropped to the ground. January 25, 2021 R1 was found on the floor by caregivers. July 19, 2021 it was noted R1 had a fall. July 21, 2021 R1 was found on the floor next to his bed. R1 had two unwitnessed reported falls in September, which R1 sustained injuries to right elbow and knee.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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: 03/11/2022

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The facility did not implement Fall Management Policy 7.69 which states,"staff will follow procedures and complete appropriate documents as outlined in the Unusual Occurrence Policy and Procedure. The Resident Care Director (RCD) will use the post-fall tracking & intervention form to analyze each fall and implement new interventions as warranted. Initiate the process upon the first fall and analyze each subsequent fall as directed on the form. Staple all fall reviews together in chronological order. Alphabetize forms according to resident’s last name and store in a fall management binder. The forms will be stored at the end of each calendar year and destroyed after 3 years."

During the the file review process, There were no post-fall tracking and intervention forms found. In addition, R1 needs and services plan does not include a fall prevention plan. R1's inflatable lap buddy documentation and plan was not included in the Needs and Service Plan. As a result, Pacifica Senior Living Modesto did follow internal fall management procedures and did not meet R1's fall risk needs.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2022 11:53 AM - It Cannot Be Edited

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: 03/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/18/2022 Section Cited	1 2 3 4 5 6 7	Reappraisals87463(a)(3)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...
	8 9 10 11 12 13 14	Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition. This requirement was not met as evidenced by. Based on record review R1's Needs and Service Plan did not include a fall prevention plan and did not included Lap buddy documentation that was found in the R1's facility medical file. This posed an immediate health and safety risk to R1.	8 9 10 11 12 13 14
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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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC809 (FAS) - (06/04)

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