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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 03/02/2022
Date Signed: 03/16/2022 09:59:11 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
11/03/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211103130829
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: 46DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa PettapieceTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to provide medical attention to resident in care.
Facility failed to report fracture of resident's arm.
Facility did not notify family of residents change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/02/2022 at 1:00 PM 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 record review, LPA Martinez determined the facility did not seek emergency medical care attention for resident 1.

Resident 1’s (R1) initial elbow injury was noted on a facility document dated September 5, 2021. On September 5, 2021, R1 sustained an unwitnessed fall with injuries. It was reported R1 yelled for help after his fall and received first aid and bandages for skin tears on right elbow and knee. R1 had another fall on September 6, 2021. It was learned R1 was found on the floor next to his bed. R1 had a small skin tear to right elbow and knee and bandages were applied on this day. 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 27-AS-20211103130829
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: 03/02/2022
NARRATIVE
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R1's responsible party rescheduled his doctor’s appointment to October 4, 2021. During the October 04, 2021 medical appointment, R1 was sent to the ER due to right arm redness and swelling. A medical note dated October 4, 2021 indicated R1 was diagnosed with an acute appearing nondisplaced extra-articular fracture of the anterior radial head.

Based on the complaint investigation and collected documentation, the facility failed to recognize R1 was exhibiting signs and symptoms of a medical emergency. As R1 sustained two falls within a two-week period and sustained injuries to his right elbow and arm. In addition to the falls, R1 sustained a lump on his forearm after his September 25, 2021 hospitalization.

Moreover, R1 was experiencing onset pain on September 27, 2021 and continuing to express pain up until his August 4, 2021 hospitalization. September 25, 2021 hospital recommendation notes included returning R1 to the hospital if any concerns arise, however, R1 was not sent out to the ER by Pacifica Senior Living Modesto facility. R1 was not sent to the hospital until his primary care physician sent him during his October 4, 2021 medical appointment; it was at this hospitalization that R1 was diagnosed with an arm fracture. Pacifica Senior Living Modesto facility failed to provide emergency medical care to R1. Furthermore, Community Care Licensing Department (CCLD) was not provided an LIC 624 Unusual Incident/Injury Report regarding R1's arm/elbow incident and fracture. The facility did not follow CCLD reporting requirements, therefore, the facility is being cited.

IMMEDIATE CIVIL PENALTY

An immediate $500.00 civil penalty shall be assessed on March 2, 2022; based on the allegation: "Facility failed to provide medical attention to resident in care." R1 sustained an arm/elbow fracture, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Due to R1 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: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20211103130829
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: 03/02/2022
NARRATIVE
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R1 was not sent to the hospital until September 25, 2021 due to sustaining redness, swelling, and a bump on right elbow. Per facility note, touching R1’s elbow caused pain. It was also, reported R1 had a bloody nose on this day. R1 returned to the facility from the hospital on September 26, 2021. Medical notes indicated follow up with primary physician within 3-5 days, in addition to, return to the emergency room (ER) if any concerns arise.

R1 reported having pain on September 27, 2021. Upon a care staff checking R1’s right arm, a lump was found on his forearm. R1 was not sent to the ER on this day. R1 continued to have pain on September 28, 2021. It was also noted R1 was retaining water and had increased swelling on this day, but R1 was not sent out to the ER. R1 was complaining of pain on September 29, 2021, however, R1 was not sent to the ER.

Pacifica Senior Living Modesto did not implement internal policy Clinical 09 Emergency Medical Care, which states, “The resident will receive emergency medical care when needed to prevent further injury or illness.” Clinical 09 Emergency Medical Care Policy also states, “The Community summons emergency medical services (call 911 )* when the resident exhibits signs and systems of distress and/or emergency condition. Examples include but are not limited to: Sudden onset severe pain. “ The facility failed to implement Clinical 09 Emergency Medical Care Policy and did not recognize R1 was in need of emergency medical care.

Additionally, facility notes do not state R1's responsible party (RP) was informed of R1's change in condition. Witness 1 (W1) reported not being informed of R1's change of condition, and last phone call received from Pacifica Senior Living Modesto facility was on September 25, 2021. Facility policy 7.60 Unusual Occurrences and Reporting states, "Upon discovery of an event. Notify the responsible party." The facility did not follow internal reporting policy and did not inform R1's responsible party of change of condition.

On September 30, 2021, it was noted R1’s arm was red and had swelling. It was also reported R1 had a scheduled doctor's appointment, and it was rescheduled due to R1 being too week to get into the responsible party's car. At this time, the facility did not send R1 to the hospital. Facility Policy 7.89 states, " Major Emergencies...If a resident experiences any of the following begin first aid and call 911...Dizziness, weakness, change in vision...Any complaints of pain in joints or limb with swelling or discoloration, abnormal size, or 'bones not naturally aligned... Always treat an incident as a major emergency, if there is any doubt in your mind." The facility failed to recognize R1 was showing signs of a major emergency.

continued...

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

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20211103130829
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2022
Section Cited
CCR
87211(a)(1)(B)
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87211 (a)(1)(B) Reporting Requirements: Each licensee shall furnish to the licensing agency such reports... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
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The Administrator agrees to: to conduct an inservice on reporting by POC Date 03/07/22. Adminstrator agrees to email inservice documents on 03/7/22
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any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirment was not met as evidenced by: based on file review, the facility did not submit a LIC 624 for R1 fracture and hospitlation. This posed a potential health and safety risk to R1.
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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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20211103130829
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited
CCR
87465(a)(g)
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87465(a)(g) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility...The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis ...
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The Administrator agrees to: to conduct an inservice on Incidental Medical and Dental Care by POC Date 03/07/22. Adminstrator agrees to email inservice documents on 03/7/22
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This requirement is not met as evidenced by: Based on observation the facility did not ensure to telephone 9-1-1 during the times R1 was exhibiting signs and symptoms of a medical emergency. R1 was expressing pain after fall incident and new found lump injury was found after fall and was not sent to the hospital. This posed an immediate health and safety risk to R1.
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Type A
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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...
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The Administrator agrees to: to conduct an inservice on obsercation of residents rting by POC Date 03/07/22. Adminstrator agrees to email inservice documents on 03/7/22
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This requirement is not met as evidenced by: Based on observation, the licensee did not ensure R1 was regularly observed for changes in health condition. This posed an immediate health, safety and risk to R1.
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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: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
11/03/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211103130829

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: 46DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa PettapieceTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility failed to provide resident with medical transportation to hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/02/200 1pm 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 record review, Pacifica Senior Living Modesto staff called 911 on September 25, 2021, and R1 was transported to the hospital via ambulance. In additon on October 4, 2021, Pacifica Seniior Living Modest staff transported R1 to his medical appointment, and Pacifica Senior Living Modesto staff transported R1 on October 4, 2021 from his primary care phyiscian office to the Emergency Room.

Due to the above noted information, although the allegation 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: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20211103130829
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: 03/02/2022
NARRATIVE
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REPEAT VIOLATIONS
  1. Violation of California Code of Regulations Section 87465(a)(g) 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.
  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. Exit interview conducted and copy of report provided was to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7