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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 10/22/2020
Date Signed: 11/02/2020 08:23:31 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
06/18/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200618153128
FACILITY NAME:PACIFICA SENIOR LIVING MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 58DATE:
10/22/2020
UNANNOUNCEDTIME BEGAN:
06:30 PM
MET WITH:Deborah Lucas TIME COMPLETED:
10:00 PM
ALLEGATION(S):
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A resident sexually assaulted another resident.
INVESTIGATION FINDINGS:
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On 10-22-2020 at 6:30 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Albert Johnson conducted an unannounced facility visit to deliver complaint investigation findings with the above allegation. LPAs met with Deborah Lucas and explained the purpose of today's visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed facility documents. Based on the investigation, the following allegation is substantiated:

1. A resident sexually assaulted another resident.

In the investigation, it was learned that resident 1 (R1) was sexually assaulted by resident 2 (R2). The facility did not protect R1 from sexual abuse.

Continued....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20200618153128
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: 10/22/2020
NARRATIVE
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Records review revealed, the facility's plan of operation section: 7.46 Abuse Prevention, Identification, & Reporting policy states: Immediate action will include the following:

1. Ensure the resident is removed from immediate danger.
2. Immediately separate involved residents. Ensure the safety of all involved residents.

The Department’s investigation discovered R2 has a history of physical and sexual behaviors towards other residents and staff per the facility notes of the resident. The facility did not have a plan in place to address R2’s behavior and how the facility will ensure other residents are safe. On 06/14/2020, R2's hand was found on R1's vagina in R1's room. A second incident was discovered during the investigation where R2 was found sitting next to R1. One of R2's hand was placed on R1's thigh. R2 had to be redirected from R1 by Staff 1 (S1).

Furthermore, the facility's policy section 7.46 indicates -Abuse Prevention, Identification, & Reporting states, "physical assault and/or sexual assault are considered crimes and must be reported to the local law enforcement agency." During an 6/24/2020 interview with Executive Director, Deborah Lucas, it was reported, "Lucas did not call or forward a copy of the SOC 341, Elder Abuse Report, to the Modesto Police Department because she was not aware it was a requirement." Deborah Lucas stated during an interview, "that since both residents have dementia law enforcement would not be able to do anything." According to facility policy 7.46, a sexual assault is considered a crime.

During the investigation, the Department contacted Modesto Police Department twice; both times the Police Department stated the facility did not notified them of the incident . The facility did not follow their own policy section 7.25.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20200618153128
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: 10/22/2020
NARRATIVE
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On an end of shift note dated 06/14/2020, it stated, " R2 touching women inappropriately...Med Tech notified." Facility Policy Care-13-Narrative Charting states, "It is the responsibility of the Resident Care Director or Designee to chart significant information from the End of Shift Note." After reviewing facility narrative charting notes, it was found that there were no entries made on 6/14/2020. In addition, there was no indication that the Care Director or designee reviewed or followed up on the End of Shift Note. The facility did not follow internal Care 13 policy. Community Care Licensing received an Unusual Incident on 06/18/2020.

As a result of this investigation, the Department finds this allegation to be substantiated. The facility did not protect R1 from being sexually assaulted by another resident. Based on the evidence through interviews, 1 caregiver observed the incident and 2 caregivers assisted R1 after the sexual abuse incident occurred. Moreover, the facility did not ensure R1 was removed from immediate danger. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

As a result of this incident, and R1 sustained serious bodily injury. The violation warrants a civil penalty assessment. At this time, the civil penalty assessment is under review, and a civil penalty determination is pending by the Department. Once civil penalty assessment has been determined, an LPA will return at a future date to assess the civil penalty.

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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20200618153128
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: 10/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
10/23/2020
Section Cited
CCR
87464(f)(1)
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87464 Basic Services(f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by:
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The facility agrees to the following. Follow up on proper placement assessments for residents prior to moving residents in and update assessment following incidents.
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Based on interviews and records review, the licensee did not ensure Care and supervision was being provided to residents in care. This posed an immediate health and safety risk to residents in care.
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Staff in-services will be given for any changes to service needs and pre-appraisals

Administrator will submit POC by
10/23/2020
Request Denied: Appeal Not Submitted Timely
Type B
10/23/2020
Section Cited
CCR
87405(d)(2)
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87405 Administrator - Qualifications and Duties:(d) The administrator shall have the qualifications specified...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The facility agrees to the following. Administrator will write out a statement of understanding regarding sexual assault regulation and reporting. Administrator will submit POC by
10/23/2020
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Based on interviews and records review, the licensee did not ensure R1 was safeguarded from sexual abuse. This posed an immediate health and safety risk to residents in care.
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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) 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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
06/18/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200618153128

FACILITY NAME:PACIFICA SENIOR LIVING MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:LUCAS, DEBORAHFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:73CENSUS: 58DATE:
10/22/2020
UNANNOUNCEDTIME BEGAN:
06:30 PM
MET WITH:Deborah Lucas TIME COMPLETED:
10:00 PM
ALLEGATION(S):
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unexplained bruises on resident's inner thigh.
INVESTIGATION FINDINGS:
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On 10-22-2020 at 6:30 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Albert Johnson conducted an unannounced facility visit to deliver complaint investigation findings with the above allegation. LPAs met with Deborah Lucas and explained the purpose of today's visit.

Throughout the course of the investigation, the Department reviewed facility documents, and conducted interviews. Based on interviews conducted by Community Care Licensing Department (CCLD), it was determined the allegation to be unsubstantiated:

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20200618153128
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: 10/22/2020
NARRATIVE
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During a interview with witness 1 (W1), it was noted that R1 is prone to bruising due to prescribed medication. W1 reported a mild injury or bump could cause a hematoma. Furthermore, R1 had a medical appointment with her primary care physician on the day of her unexplained injury. 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(s) did or did not occur, and therefore the allegation is unsubstantiated.

An exit interview was conducted with Deborah Lucas and a copy of this report was provided to Deborah Lucas via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6