507004251-10-23-2020-27-AS-AMAZ-BUNKYC-20201023081853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 10/22/2020
Date Signed: 10/23/2020 08:29:18 AM

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:	LUCAS, DEBORAH		FACILITY TYPE:	740
ADDRESS:	2325 ST PAUL'S WAY		TELEPHONE:	(209) 491-0800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	73	CENSUS: 58	DATE:	10/22/2020
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	06:30 PM
MET WITH:	Deborah Lucas		TIME COMPLETED:	10:00 PM

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On 10-22-2020 at 6:00 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Albert Johnson conducted an unannounced facility visit to conduct a case management. LPAs met with Deborah Lucas and explained the purpose of today's visit.

The purpose of the case management visit is to follow up on various deficiencies learned throughout a complaint investigation. The following deficiencies were discovered:

Deborah Lucas reported she monitors R1 via surveillance camera. Moreover, R1's admission agreement does not address how the facility will protect R1's privacy, and how the facility will maintain R1's dignity rights while being monitored via surveillance camera. Furthermore, on R1's admission agreement, it states, "common area surveillance cameras are not monitored by staff, nor nanny cameras or any other surveillance cameras are permitted in residents' apartments due to dignity and privacy rights."

The facility did not maintain a current, written definitive plan of operation. The facility's plan of operation shall include changes that will affect the services to residents and shall be submitted to the licensing agency for approval. Such as, monitoring residents by use of surveillance cameras.

A concern that was discovered was caregiver staffing numbers. In multiple interviews, it was noted that the facility is short staffed. On an interview with Deborah Lucas, she stated, "the facility is sometimes short staffed."

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020

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: 10/22/2020

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In an interview with Executive Director, Deborah Lucas, she reported a fully staffed shift would consist of AM and PM shifts having 2 med-Techs; 1 caregiver assigned to each neighborhood; and 1 floater. The night shift is fully staffed with 3 caregivers and 1 med-tech to oversee the entire facility.

The facility staffing policy 2.25 states, "This community will always have on staff a minimum of one caregiver for each shift and in each house day, evening and night." According to June's work schedule, the night shift consisted of 2-3 caregivers. As a result, not all houses have an assigned caregiver at the night shift.

S1 reported feeling concerned about the facility being short staffed. For instances, on 07/13/2020 night shift, S1 reported having to oversee four communities due to other caregivers not showing up. Policy 2.25 states, "The shift supervisor is responsible for assuring sufficient staffing on their respective shifts to meet the needs of the residents." The facility did not follow facility policy 2.25, as of May and June night monthly schedules shows only 2-3 employees scheduled to work.

Another concern is locking residents' bedroom doors. Staff 2 (S2) reported caregivers lock residents' bedrooms when residents are not in their room, or when residents are resting on their bed. S2 reported residents' bedroom doors open from the inside of the room, therefore, residents are not locked in. S2 reported residents have Dementia, and doors are locked to keep resident from entering wrong bedrooms. Staff 1, 3, and 4 reported residents' bedroom door is locked to keep residents from going into the wrong bedroom. Deborah Lucas reported locking doors is not a policy on 7/28/2020. The facility’s plan of operations does not indicate that residents’ bedrooms will be locked to keep residents from entering other residents’ bedrooms. The facility did not follow their plan of operation.

An exit interview was conducted with Deborah Lucas. A copy of this report was provided to Deborah Lucas via email. LPA Martinez emailed the report to Deborah Lucas due to covid-19 precautionary measures. Deborah Lucas signed the report, and emailed the report LPA Martinez. the following deficiencies were cited, per Title 22 Regulations, The deficiencies were cited on 809-D, and appeals rights given to the administrator.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 10/22/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
	1 2 3 4 5 6 7
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Request Denied: Appeal Not Submitted Timely Type B 10/30/2020 Section Cited	1 2 3 4 5 6 7	87208 Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation...(2) A copy of the Admission Agreement...(3) Statement of admission policies and procedures...(5) Staffing plan, qualifications and duties.
	8 9 10 11 12 13 14	This requirement was not met by:Based on interviews and file reviews, the licensee did not maintain a current plan of operation. This posed an potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020

LIC809 (FAS) - (06/04)

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