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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 12/08/2022
Date Signed: 12/08/2022 12:47:01 PM

Document Has Been Signed on 12/08/2022 12:47 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:MANDY TAYLORFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 110CENSUS: 65DATE:
12/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Robert Roby, AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/08/22 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced case management visit to follow up on the criminal record exemption status on staff (S1). LPA explained the purpose of the visit with administrator (ADM).

ADM stated that S1 has been terminated since 08/29/22 and no longer works at the facility. Review of Guardian Portal on 12/08/22 shows S1 was associated on 02/22/22 with the facility and still an active employee with no separation or disassociation date. LPA obtained a copy of S1's separation form from ADM dated 08/29/22.

Immediate civil penalty of $500 assessed during visit for employment of a non-cleared/excluded individual.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2022 12:47 PM - It Cannot Be Edited


Created By: Daisy Panlilio On 12/08/2022 at 12:22 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2022
Section Cited
CCR
87355(a)

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The Department shall conduct a criminal record review of all individuals ...any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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Immediate civil penalty of $500 assessed during visit due to employment of a non-cleared individual on 03/27/22.


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This requirement was not met as evidenced by staff (S1) not having criminal record clearance prior to employment which posed an immediate health & safety risk to residents in care.
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Deficiency corrected during visit. Administrator submitted copies of S1 termination documents dated 08/29/22.

Administrator also updated Guardian Portal and disassociated S1 from employment list effective 12/08/22.

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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:Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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