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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:00:37 PM

Document Has Been Signed on 02/17/2022 04:00 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: 74DATE:
02/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anoop Nair, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 2/17/2022 at 3:00PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Administrator, Anoop Nair.

While LPAs were conducting a complaint investigation to deliver findings, the following deficiency was observed.

During complaint investigation, it was identified that R1 did not have an updated medical assessment on file. R1's medical assessment on file was dated 3/20/2019.

Additionally, facility did not submit a death report for resident who expired and was tested positive for COVID-19. During the facility's outbreak, staff did not report positive cases to CCLD per reporting guidelines outlined in Title 22.

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

Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 02/17/2022 04:00 PM - It Cannot Be Edited


Created By: Grace Luk On 02/17/2022 at 03:15 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
87705(c)(5)

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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...at least annually... This requirement is not met as evidence by:
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Executive director has agreed to obtain current medical assessment for R1 and submit a copy to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having an updated medical assessment for R1 which poses a potential health and safety risk to the persons in care.
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Type B
02/25/2022
Section Cited
CCR87211(a)(1)

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Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement is not met as evidence by:
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Executive director has agreed to review reporting requirements and submit self-certification to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not reporting COVID positive cases and submit death reports which poses a potential health and safety risk to the persons 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: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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