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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507004251
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:14:08 AM


Document Has Been Signed on 10/26/2022 10:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MODESTOFACILITY NUMBER:
507004251
ADMINISTRATOR:THERESA L PETTAPIECEFACILITY TYPE:
740
ADDRESS:2325 ST PAUL'S WAYTELEPHONE:
(209) 491-0800
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:0CENSUS: 0DATE:
10/26/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Theresa PettapieceTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Avelina Martinez and Arielle Pascua arrived at this facility unannounced to conduct a case management visit on 10/26/2022. This visit is to deliver a civil penalty regarding “resident was not provided medical attention in a timely manner.” LPA Avelina Martinez met with Theresa Pettapiece and explained the purpose of the visit.

On December 1, 2021, the Department received a complaint alleging, “Resident was not provided medical attention in a timely manner.” The Department conducted an investigation and determined resident (R1) had an unwitnessed fall on November 19, 2021 and was sent to the Emergency Room (ER). 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 discharged from the hospital and transferred into the care of the facility 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.”

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SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2022
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On November 25, 2021, R1 had a second unwitnessed fall. 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; but the physician did not respond to the facility until December 2, 2021; six days later. The facility did not follow the aftercare instructions provided to R1 upon their discharge from the hospital on November 24, 2021, and R1 was not sent to the ER after stating they were in a lot of pain, nor was there a person present to keep the resident from falling. A third unwitnessed fall occurred on November 29, 2021 at 5:30 p.m. It was reported R1 complained of pain on right-side fractured rib. R1 was not sent to the hospital.

On March 23, 2022, the Department substantiated the allegation that the “Resident was not provided medical attention in a timely manner” and the licensee was cited for violating the California Code of Regulations Title 22 (22 CCR), § 87465(j) Incidental Medical and Dental Care, which states, “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.” The licensee did not ensure R1 received emergency timely medical attention causing R1 to be in extreme pain for extended period of time, posing an immediate safety risk to a resident in care. The licensee was informed that a civil penalty was still being determined and may be assessed based on Health and Safety (HSC) §1569.49.

The Department has concluded an analysis and has determined that a civil penalty per HSC §1569.49(f), in the amount of $10,000 is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code (WIC) §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery or physical rehabilitation.”

This is evidenced by the licensee’s failure to ensure proper care and supervision for R1, resulting in R1 sustaining multiple fractures which required hospitalization and causing extreme pain.

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

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/26/2022
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Today, 10/26/2022, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 23, 2022, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to Theresa Pettapiece, Executive Director and originals were signed.

An exit interview was conducted. A copy of the report was issued, and Appeal Rights provided. Theresa Pettapiece, Executive Director signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3