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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507004251
Report Date: 12/28/2020
Date Signed: 12/29/2020 09:11:25 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
05/27/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200527165031
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:
12/28/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Deborah LucasTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident’s living accommodations were unsanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings von 12/28/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, and reviewed hospice records. The investigation allegation is as follows:

1. Resident’s living accommodations were unsanitary.

Continued...
Substantiated
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
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 8
Control Number 27-AS-20200527165031
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: 12/28/2020
NARRATIVE
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On 3/24/2020 via email, the authorized representative informed Theresa Pettapiece she had concerns about the side effects of moving R1 into the main building. It was reported R1 resided in the main building in the past, but this building caused R1 to have increased anxiety. As a result, R1 was moved out of the main building. On 03/25/2020 Pacifica Senior Living Modesto’s email reported, R1 required (2) person hands on assist for transfers and other basic care services. It was also reported that the main building caregivers have additional assistance from medtechs and other staff to complete R1’s required health care needs.

However, on 05/23/2020, R1 was found laying on unsanitary stained mattresses. Staff 1 (S1) reported working at the facility on 05/23/2020. S1 reported R1 was found with no socks and in a soaked brief on 05/23/2020. In addition, R1 was captured on video laying on unsanitary stained mattresses that were located on the floor on 05/23/20. LPA Martinez viewed the 05/23/2020 video, which was uploaded to a social media outlet. It appeared R1 was living in unsanitary conditions. The facility did not adhere to Title 22 regulations. The resident's mattresses were not in good repair and sheet protector was missing. The facility did not provide basic care services, as R1 was found in a soaked brief.

Moreover, the facility did not safeguard R1 from hazards. It was captured on the 5/23/2020 video that R1’s mattresses were placed against a wall, and R1’s head rested near an electric socket. The facility failed to follow Title 22 Dementia regulations, such as, making items inaccessible that could constitute a danger to R1. R1’s mattresses were also blocking closet doors and preventing the use of the closet. The facility did not provide sufficient space to accommodate R1’s comfort and safety.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 27-AS-20200527165031
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: 12/28/2020
NARRATIVE
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LPA Martinez determined the facility did not provide basic care to R1. LPA Martinez determined the facility did not provide R1 physical accommodations and services. The facility did not provide safe and healthful living accommodations.

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.

Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. In addition, 87468.1(a)(2)
was previously cited on 06/02/2020; therefore, a civil penalty shall be assessed for a repeat violation within a 12-month period during this visit. Appeals rights document given to the facility.

An exit interview was conducted with Deborah Lucas via telephone 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: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
05/27/2020 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20200527165031

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:
12/28/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Deborah LucasTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility failed to notify authorized representative of the resident’s room change.
Facility failed to notify authorized representative of the resident’s change in health condition.
Facility did not allow residents to choose preferred hospice agency.
Resident was overmedicated.
Facility failed to safeguard resident’s incontinence supplies.
Facility failed to safeguard resident’s personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver investigation findings on 12/28/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Deborah Lucas.

Throughout the course of the investigation, LPA Martinez conducted interviews, reviewed facility documents, and reviewed hospice records. The investigation allegations are as follows:

1. Facility failed to notify authorized representative of the resident’s room change.
2. Facility failed to notify authorized representative of the resident’s change in health condition.
3. Facility did not allow residents to choose preferred hospice agency.
4. Resident was overmedicated.
5. Facility failed to safeguard resident’s incontinence supplies.
6. Facility failed to safeguard resident’s personal belongings

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: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20200527165031
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: 12/28/2020
NARRATIVE
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LPA Martinez obtained emails and other documentation regarding resident’s 1 (R1) significant health changes and room change request due to an increase in level of care. It is noted on a 3/25/2020 email that both Pacifica of Senior living Modesto staff and the authorized representative agreed to move R1 to a higher level of care community in the main building. Moreover, Deborah Lucas emailed the authorized representative a copy of the current needs and service plan, which discussed R1’s health changes.

LPA Martinez reviewed 01/01/2020 thru 05/31/2020 medication MAR sheets. It was determined medications were given as prescribed to R1 from 01/01/2020 to 03/31/2020. LPA Martinez learned that on 04/30/2020, Centrum Silver was not administered. On May 29, 30, and 31st, R1 was not administered the following medication: Pantoprazole Sodium, Trazodone, Levothyroxine, Centrum Silver. Melatonin was not administered on May 28, 29, 30, and 31st. The facility did not administer medication as prescribed during April and May of 2020, and LPA Martinez determined there was not a preponderance of evidence to substantiate R1 was over medicated.

LPA Martinez reviewed the Community Care Hospice documents, and it was learned that R1’s authorized representative conducted phone calls with Community Care Hospice. On 05/20/2020, the authorized representative informed Community Care Hospice, the family would need more time to discuss the hospice plan. On 05/21/2020, the authorized representative called the facility to start services. Therefore, it was determined the authorized representative had the ability to choose their preferred hospice company.

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 27-AS-20200527165031
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: 12/28/2020
NARRATIVE
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Furthermore, R1’s signed admission agreement included client/resident property and valuables LIC 621. However, the LIC 621 was not completed by the facility. LPA Martinez also requested pictures of the missing furniture from the complainant, however, LPA Martinez never received furniture pictures. Therefore, LPA Martinez was not able to substantiate the missing furniture allegation. LPA Martinez determined there was not a preponderance of evidence to prove the facility did not safeguard R1’s incontinent supplies.
Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted with Deborah Lucas via telephone 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: 12/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20200527165031
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: 12/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2020
Section Cited
CCR
87705(f)(1)
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Care of Persons with Dementia(f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Administrator agrees to conduct an all staff training on hazards and items that can constitute a danger to residents. Administrator will email training agenda by 12/30/2020
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure electric socket was inaccessible to R1. This posed an immediate health and safety risk to R1.
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Administrator will email training materials to LPA by 01/12/2021.
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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: 12/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20200527165031
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: 12/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2020
Section Cited
CCR
87468.1(a)(2)
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87468.1Personal Rights of Residents...(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator agrees to conduct an all staff training on personal rights by 1/12/2021. Administrator agrees to email LPA the personal rights meeting agenda by12/30/2020
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure R1 was provided safe and healthful accommodations. 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) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2020
LIC9099 (FAS) - (06/04)
Page: 8 of 8