507004251-5-19-2022-27-AS-CACL-CEKTRE-20220519145724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 05/19/2022
Date Signed: 05/19/2022 02:28:59 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
02/02/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220202103108

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: 38	DATE:	05/19/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Theresa Pettapiece		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not paying bills- in financial distress

INVESTIGATION FINDINGS:

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On 05/19/2022 at 2:00 PM, an office meeting was held via phone call. The phone call meeting was in regards to delivering complaint findings. LPA Martinez spoke with Theresa Pettapiece and explained the purposed of today's phone call meeting.

As a result of the above allegation, the Department requested a solvency audit. The Department's Audit Section conducted an financial investigation, and the findings are as follows:

1. Pacifica Senior Living Modesto facility does not have a sound financial plan in place.
2. Pacifica Senior Living Modesto is operating at a net loss and does not have an adequate cash reserve based on the size of the facility.
3. Pacifica Senior Living Modesto does not generate sufficient income to meet the operating costs.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220202103108

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: 05/19/2022

NARRATIVE

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4. Pacifica Senior Living Modesto did not provide all requested documents by Department and did not
maintain adequate financial records.
5. Pacifica Senior Living Modesto Licensee did not exercise general supervision over the affairs of this
licensed facility.

It was learned, the Licensee was paying facility food expenditures and utility bill on time. However, the facility is operating at a net loss, and based on the gathered information the facility does not generate enough income from day to day operations to cover expenses. In addition, it was determined the facility does not have a financial plan that complies with Title 22 regulations. Moreover, throughout this audit investigation, the facility did not provide all requested documents to the Department.

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.

An exit interview was conducted with Theresa Pettapiece via telephone, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220202103108

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: 05/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/23/2022 Section Cited CCR 87205(a)	1 2 3 4 5 6 7	87205(a) Accountability of Licensee Governing Body The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.	1 2 3 4 5 6 7	Facility Agrees to ensure sufficient resources to meet operating costs for care of the residents until the facility is closed. Facility staff will provide weekly updates on how the facility is doing starting 05/23/2022 until further notice.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on observation and record review: the Licensee did not provide general supervision to ensure the facility was in good financial shape and ensure the facility was following operations policies that are in conformance with Title 22 Regulations. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC9099 (FAS) - (06/04)

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