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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 03/02/2022
Date Signed: 03/04/2022 07:15:35 AM

Substantiated


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
11/17/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211117162655
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: 40DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Theresa PettapieceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Residents has had multiple unexplained falls while in care
Resident has lice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) made an unannounced visit to the facility on 03/02/2022 at 02:00 p.m. to investigate the allegations listed above. LPA met with Administrator Theresa Pettapiece and explained the purpose for today’s visit.

Regarding the allegation resident has had multiple unexplained falls while in care. Based on interviews and facility records it was found that R1 had nine falls during a three month span from September 2021 through November 2021. Staff 3 recommended that R1 have a one on one staff and also attempted to get safety equipment for R1. However, R1’s family could not pay for a one on one staff and R1 never received safety equipment. During interview with Staff 3 it was reported that the facility could not keep R1 safe, as R1 needed additional assistance and the facility could not provide that type of care. Based on the information provided through staff interviews and documentation, this allegation was SUBSTANTIATED. A finding that the complaint is substantiated means that there was a preponderance of evidence to prove that that the alleged violation did occur as alleged.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
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: 1 of 5
Control Number 27-AS-20211117162655
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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Throughout the course of the investigation, LPA Hurt reviewed facility records and spoke with facility staff. Complaint 27-AS-20211101160116 has been completed, and it was determined this (27-AS-20211117162655) complaint share some allegations. The shared allegations are as follows: Resident has lice. Moreover, it was learned Resident 1 was diagnosed with head lice on October 28, 2021 and received head lice treatment on this day. Resident 1's hair and scalp were inspected for lice on November 5, 2021, and it was noted Resident 1 continued to have lice. Resident 1 was treated for head lice on this day and was cleared on November 10, 2021. Therefore this allegation is SUBSTANTIATED, there will be no additional deficiencies cited as the facility was cited on 12/27/2021 related to Resident 1 having lice. Complaint 27-AS- 27-AS 20211101160116 citations can be found on the 12/27/2021 report.


This is an amended report. Per title 22 the following deficiencies are being cited during this visit and civil penalties assessed. Exit interview was conducted with facility staff Reshmika Sharma and a copy of this report along with appeal rights and confidential names list was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
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 5
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
11/17/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211117162655

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: 40DATE:
03/02/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Theresa Pettapiece TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained a fracture while in care
Staff did not safeguard residents personal property
Staff did not administer residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) made an unannounced visit to the facility on 03/02/2022 at 02:00 p.m. to investigate the allegations listed above. LPA met with Administrator Theresa Pettapiece and explained the purpose for today’s visit.

Regarding the allegations staff did not safeguard resident’s personal property. During this investigation LPA reviewed facility records “Inventory of Personal Effects” form for Resident 1 listing all items brought into the facility upon moving in, and emails documenting what Resident 1’s daughter listed as missing. The “inventory of personal effects” document signed when Resident 1 moved in did not list several of the items Resident’s daughter listed as missing when she vacated the facility. The document is normally signed again upon vacating the apartment to account for all belongings, but Resident 1's daughter did not sign the form upon vacating. The facility Administrator did credit Resident 1’s account for several items that Resident 1's daughter listed as missing. The exact items taken when Resident 1 vacated the apartment is unclear.
Continued on 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
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: 3 of 5
Control Number 27-AS-20211117162655
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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Continued from 9099..

Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation resident sustained a fall while in care: Per incident reports and medical records, Resident 1 (R1) sustained a fall that resulted in a fracture. R1 was diagnosed with a right femoral neck fracture and underwent surgery. R1 was discharged to a skilled nursing facility and returned to Pacifica Senior Living after recovery. Per the Internal Incident Report, R1 sustained the fall and was found by former staff member (S1). During S1's interview it was reported that when found, R1 stated someone had pushed R1, but there was no one around that could have pushed R1. S1 also stated that she was off at 0600 hours, and EMS had not responded, which contradicts the medical records. According to facility records, Staff 2 (S2) responded to assist R1 regarding the fall; however, during interview S2 could not provide any information regarding the fall as she could not remember the incident. Prior to this incident R1 had sustained a previous fall but was not considered a fall risk at that time. Due to the lack of information regarding the fall, it is unclear how the fall occurred. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegations staff did not administer residents’ medications Based on records reviewed Resident 1 was being administered medications by facility staff. LPA reviewed facility document titled " narrative charting" dated 09/28/2021 with detailed notes documenting Resident 1 being given medications. LPA reviewed notification form faxed to pharmacy informing them not to send Resident 1 new refills because Resident had medication supply available. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

This report has been amended. No deficiencies cited per Title 22 Regulations exit interview was conducted and a copy of this report was given to Administrator Reshmika Sharma. .
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
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: 4 of 5
Control Number 27-AS-20211117162655
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
87464(d)
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87464(d) Basic Services. A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.
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Administrator agrees to conduct in service training on 03/07/2022 including a "fall risk plan" training.
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The following has not been met as evidenced by: Based on interviews, CCL investigation, and records reviewed Resident 1 had multiple falls despite staff being aware Resident 1 needed higher level of care which poses an immediate risk to residents in care.
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ILS
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
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 5