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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 08/16/2021
Date Signed: 08/16/2021 02:46:06 PM

Document Has Been Signed on 08/16/2021 02:46 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 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: 73DATE:
08/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Rammy Kaur, Executive DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/16/2021 at 1:01PM, Licensing Program Analysts (LPAs) G. Luk and G. Clark arrived unannounced to conduct a case management inspection in regards to incident report received on 8/9/2021. LPAs met with Executive Director, Rammy Kaur.

Incident report dated 8/9/2021 revealed that R1 AWOL and facility notified law enforcement and R1's responsible party. R1 was found by police and was taken to Kaiser Hospital.

Interview with S1 revealed that R1 left the facility during the evening time when staff was exiting the building. S1 stated R1 was found by the police and taken to Kaiser Hospital. Family member took R1 back home and returned to the facility on Friday.

During record review, LPAs observed that physician's report dated 4/1/2021 stated that R1 cannot leave the facility unassisted.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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 08/16/2021 02:46 PM - It Cannot Be Edited


Created By: Grace Luk On 08/16/2021 at 01:32 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 UNION CITY
FACILITY NUMBER: 019200509

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited
CCR
87705(k)(6)

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Care of Persons with Dementia. Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not
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Executive Director has conducted in-service training for all staff regarding elopement protocol and alarm system. A copy of training was obtained.
Deficiency cleared during inspection
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met as evidence by:
Based on record review, licensee did not comply with the section cited above due to resident AWOL which poses a potential health and safety risk to the residents in care.
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Type A
08/17/2021
Section Cited
CCR87303(a)

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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times....
This requirement is not met as evidence by:
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Executive Director has agreed to submit a written plan to address elopement of residents in Memory Care Unit to CCLD by POC date. ED will also provide update on when the alarm sound will be changed.
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Based on observation, licensee did not comply with the section cited above by having a low audible delayed egress doors in Memory Care Unit which poses an immediate health and safety risk to the residents in 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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