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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601394
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:30:49 PM

Document Has Been Signed on 04/18/2022 01:30 PM - 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:CASTRO, GILBERT MFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 90CENSUS: 59DATE:
04/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Lisa Lostica, Senior Business Office ManagerTIME COMPLETED:
01:45 PM
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On 4/18/2022, Licensing Program Analyst (LPA) C. Lin conducted a case management visit while delivering complaint investigation findings, and met with the Senior Business Office Manager, Lisa Lostica, LPA explained the purpose of the visit.

During an investigation conducted by the Department, records obtained indicate that R1 had multiple falls between 09/2019 and 02/2020. On 02/07/2017, the resident was diagnosed with Dementia. There is no documentation to show that the facility conducted reassessment of the resident. The resident’s Appraisal Needs and Services Plan is not updated for changes in condition. Staff interviewed state they were unaware of R1’s Dementia diagnosis.

A deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.



Exit interview conducted with xxxx. A copy of this report and Appeal Rights was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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 2
Document Has Been Signed on 04/18/2022 01:30 PM - It Cannot Be Edited


Created By: Catherine Lin On 04/18/2022 at 12:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PACIFICA SENIOR LIVING SAN LEANDRO
FACILITY NUMBER: 015601394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
CCR
87463(a)

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87463(a) Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
This requirement is not met as evidenced by:
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By POC date, Administrator will review and ensure that all Appraisal Needs and Services Plans (ANS) are current. Administrator will submit to CCL self-certification stating that all ANS have been reviewed, updated and signed by resident/responsible person.
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Based on records obtained by the Department, R1 has fallen multiple times between 09/2019 and 02/2020. There is no documentation to show that the facility conducted a reassessment of the resident and updated the resident’s Needs and Services Plan for changes in condition following these falls which poses a potential risk to the health and safety of clients under 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:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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