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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:57:25 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2021 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20210201132137
FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bernadette Bender, Memory Care DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff failed to keep resident’s room clean and free of incontinence odors -
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) C. Fowler arrived at the facility on 04/28/2022 to deliver findings on the above allegations. LPA met with Bernadette Bender, Memory Care Director and explained the purpose of visit.
On 2/5/2021, LPA L. Fontanilla initiated 10-day investigation, obtained records and conducted televisit with former Executive Director Joyce Latimer and former Resident Services Director (RSD) Amelia Camat. On 11/24/2021, LPA L. Fontanilla interviewed RSD Baljinder Singh. On 11/30/2021, LPA L. Fontanilla reviewed Resident 1 (R1’s) Needs and Services Plan and interviewed Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3).

In an interview conducted by LPA Fontanilla with former RSD on 2/5/21, RSD admits that R1’s room has urine smell. RSD states R1 would not call staff to assist in using the commode and there were times that R1 would miss the commode and urine ends up in the carpet.

(cont on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 6
Control Number 15-AS-20210201132137
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 04/28/2022
NARRATIVE
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Cont from 9099

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20210201132137
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER: 019200509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
87625(b)(3)
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(b) In addition to Section 87611, General Requirements for Allowable... the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry and that ...incontinence.

This requirement is not met as evidenced by:
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Administrator will conduct training with caregivers and housekeepers on Sec 87625 Managed Incontinence and submit proof of training to CCL by 5/05/2022.
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Based on investigation:

During the televisit conducted by LPA on 2/5/2021, former RSD confirmed with LPA that there was urine smell and stains on the carpet in R1’s room which poses a potential risk to health and safety of client
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2021 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20210201132137

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bernadette Bender, Memory Care DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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2
3
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9
Staff failed to assist resident with showers

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) C. Fowler arrived at the facility on 04/28/2022 to deliver findings on the above allegations. LPA met with Bernadett Bender, Memory Care Director and explained the purpose of visit.
On 2/5/2021, LPA L. Fontanilla initiated 10-day investigation, obtained records and conducted televisit with former Executive Director Joyce Latimer and former Resident Services Director (RSD) Amelia Camat. On 11/24/2021, LPA L. Fontanilla interviewed current RSD Baljinder Singh. On 11/30/2021, LPA L. Fontanilla reviewed Resident 1 (R1’s) Needs and Services Plan and interviewed Staff 1 (S1), Staff 2 (S2) and Staff 3 (S3).
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2021 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20210201132137

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bernadette Bender Memory Care DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
3
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9
Staff failed to maintain resident's equipment clean and sanitary
INVESTIGATION FINDINGS:
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On 11/30/2021, LPA L. Fontanilla interviewed 3 staff who all state that caregivers are responsible in cleaning residents’ commode, wheelchair and other equipment as needed. And if thorough cleaning/disinfecting is needed, the housekeepers are responsible. Photos obtained by LPA show commode bucket which appears to have yellowish stains. The commode chair was observed with plenty of crust all over.
On 4/19/2022, LPA Fontanilla interviewed S8 who has been working at the facility for 5 years. LPA showed S8 photos of R1’s commode. S8 states the commode in the photo does not look like R1’s commode because the caregivers clean R1’s commode regularly. S8 added that since R1 is incontinent, caregivers make sure the commode is cleaned.
The above allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2021 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20210201132137

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:JOYCE LATIMERFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 75DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Bernadette Bender Memory Care DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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9
Facility is in disrepair
INVESTIGATION FINDINGS:
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On 11/30/2021, LPA L. Fontanilla interviewed S1, S2 and S3. S1 and S2 state that R1 needs reminders with showers and standby assist once in the shower. However, both staff state that R1 would always refuse to take his shower which is scheduled 2x per week. And that they cannot force R1 to take his showers. S2 states that each time R1 refuses to take a shower, S2 would assist R1 with sponge bath and makes sure that R1 is wearing clean clothes before going to breakfast. Based on interview with former RSD, caregivers usually notify the supervisor each time R1 refuses to take a shower but there are no records available.
On 11/30/2021, LPA L. Fontanilla reviewed R1’s Needs and Services Plan. The plan
indicates “Bathing, assistance required, partial assist, give encouragement to bathe self with wash cloth to physical limitations.”

Based on interviews conducted and record review, the above allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6