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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601394
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:08:34 PM

Unsubstantiated


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
11/26/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20241126152636
FACILITY NAME:PACIFICA SENIOR LIVING SAN LEANDROFACILITY NUMBER:
015601394
ADMINISTRATOR:BERTUCCI, GLENDA TFACILITY TYPE:
740
ADDRESS:348 W JUANA AVETELEPHONE:
(510) 357-1691
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:90CENSUS: 47DATE:
12/04/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LISA LOSTICA BUSINESS OFFICE MANAGERTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff inappropriately locked resident’s room.
INVESTIGATION FINDINGS:
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On 12/04/2024 at 10:00AM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to open a 10-day initial complaint for the allegation above. Upon arrival, LPA met with Business Office Manager, Lisa Lostica and explained to her the reason for the visit.

During the course of the investigation, the Department conducted interviews with residents and staff, and witness. The Department obtained and reviewed the facility & staff roster, R1 Physician report residents assessment, needs and service plan.

Allegation: Staff inappropriately locked resident’s room
Investigation Finding: Un-substantiated

Continue on LIC 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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 2
Control Number 15-AS-20241126152636
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 SAN LEANDRO
FACILITY NUMBER: 015601394
VISIT DATE: 12/04/2024
NARRATIVE
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Continue from LIC 9099

It was reported to the Department that staff inappropriately locked resident’s room. The department conducted interviews and reviewed documents which reveal that residents apartments are locked and all responsible staff has master keys to get into the apartments for care and emergency services if needed. Therefore, this allegation is un-substantiated.

This agency has investigated the complaint alleging Staff inappropriately locked resident’s room. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2