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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 03/23/2022
Date Signed: 03/23/2022 12:24:19 PM

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
12/01/2021 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211201131516
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: 38DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident was not provided medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/23/2022 at 10:00 AM to deliver complaint findings, LPA met with Theresa Pettapiece and explained the purpose of the visit.

Based on a file review and interviews, it was determined resident 1 (R1) was not provided medical attention in a timely manner. R1 sustained multiple falls and the following injuries: rib fracture, contusion of right elbow, hematoma to right forehead, and severe pain.

R1’s first unwitnessed fall was on November 19, 2021 and was sent to the Emergency Room (ER). During this ER visit, R1 was diagnosed with a contusion to right elbow, a hematoma on the right arm, and a head injury. The ER after care instructions state, “If you believe that your condition has worsened or new problems develop, please return to the emergency department or see your doctor immediately.”

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: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 4
Control Number 27-AS-20211201131516
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: 03/23/2022
NARRATIVE
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On November 20, 2021, R1 complained of severe pain and was sent to the ER. At this ER visit, R1 was diagnosed with a rib fracture. R1 was hospitalized for four days; R1 was discharged from the hospital and transferred into the care of Pacifica Senior Living Modesto on November 24, 2021. Hospital instruction notes state the following, “ please call the Trauma and Acute Care Surgery if you have increase in pain, fevers, chills, persistent nausea or diarrhea, notice increase redness or drainage at the wound site, pain not controlled by pain medication or are otherwise ill feeling. If it is severe, or the office is closed, please come to the Emergency Department.”

Furthermore, the hospital instructions state, “Until you are able to care for yourself fully and safely, you should be in the care of another responsible adult. This is to ensure you can safely access your food, medications, restroom and medical appointments. It is also important someone can help keep you from falling and can help recognize if you are getting sick.” On November 25, 2021, R1 had a second unwitnessed fall. R1 was found on the floor next her bed. R1 was not sent to the hospital on this day. After the fall R1 was repositioned to help support previous injury.

R1 reported being in a lot of pain on November 26, 2021. According to facility notes, R1 was screaming in pain when being transferred or pulled up on wheelchair. The facility staff communicated with R1’s physician on November 26, 2021 via fax and requested another pain medication. R1’s physician responded via fax on December 2, 2021 and requested a medical appointment but did not address the pain concern. The facility failed to provide medical attention in a timely manner. The facility also failed to follow hospital discharge instruction notes, and R1 was not sent to the ER after stating a lot of pain.

A third unwitnessed fall occurred on November 29, 2021 at 5:30 PM. Facility notes contained conflicting information. Care staff reported R1 having a new bump on forehead. The Resident Care Director (RCD) reported completing a full assessment on R1 and took a picture of R1’s forehead and reported no new bump on forehead. However, it was reported R1 complained of pain on right-side fractured rib. R1 was not sent out to the hospital on this day. The facility contacted R1’s physician regarding the fall on November 30, 2021 via fax at 9:03 AM. A facility notes indicates R1’s physician responded on November 30, 2021, which the only health instruction was continuing monitoring R1 to prevent further falls. There is no other documentation that address R1’s fractured rib pain.

Continued...

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

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20211201131516
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: 03/23/2022
NARRATIVE
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Based on Internal facility medical emergency 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: …Fall with deformity, severe pain or head injury.” The facility failed to recognize R1’s medical emergency care and did not address R1’s pain.

Since R1’s November 20, 2021 hospitalization rib fracture diagnosis and November 24, 2021 hospital discharge, R1 continued to sustain falls with injuries and pain. It was determined the facility did not follow the hospital patient care instructions after hospitalizations. For one, R1 was to return to the hospital if condition has worsened or new problems develop. The hospital also advised to have R1 to return to the ER if there was any severe pain. Hospital instructions also mentioned the importance of providing care to help prevent falls after rib fracture. R1 stated having a lot of pain on November 26, 2021 and on November 29, 2021 and R1 was not sent out to the ER on these days. R1 was not sent out to the ER after the November 25, 2021 and the November 29, 2021 falls with injuries and pain

According to facility notes, the first recorded fall prevention review was on November 30, 2021 by the facility Resident Care Director (RCD). A Physician’s order for fall prevention durable medical equipment (DME) was received on November 30, 2021. However, there is no documentation that states R1, received fall prevention DME, such as, landing pad, side rails, and a safety alarm.

R1 suffered multiple falls with serious bodily injuries and did not receive medical attention in a timely manner. As a result, an immediate $500.00 civil penalty shall be assessed on March 23, 2022; based on the allegation: " Resident was not provided medical attention in a timely manner." R1 sustained bodily injury and severe pain, 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. As a result of this investigation, the Department finds this allegation to be substantiated. A finding that the complaint is substantiated means that the allegation is 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 this report was provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20211201131516
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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/24/2022
Section Cited
CCR
87465(j)
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87465 (j) Incidental Medical and Dental Care: In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications.
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The administrator agrees to: To have a back up supply of fall prevention DME for residents to use until residents' Dr's ordered DME arrives at the facility. Administrator will email fall prevention dme plan by POC date 03/24/2022. Facility conducted a fall assessment training last week.
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The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff. This requirement was not met as evidence by: based on record review R1 did not receive emergency medical services and assistance with medication in timely manner. This posed an immediate 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: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4