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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:03:26 PM

Substantiated


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
01/24/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240124152114
FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:ROBY, ROBERT BFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 57DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marie Lagasca-Cruz, Executive DirectorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not notify resident's authorized person of injury
INVESTIGATION FINDINGS:
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On 12/6/2024 at 10:00am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Marie Lagasca-Cruz and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witness, and obtained and reviewed records, including medical records from Kaiser of San Leandro for R1.

Allegation: Staff did not notify resident's authorized person of injury

During interview with W1 it was stated that the facility did not become aware of R1’s fall until W1 spoke with former staff (S2). Department reviewed incident report that was

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 6
Control Number 15-AS-20240124152114
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 UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC9099.

submitted to CCLD, which indicated R1 had complained of pain to his arm to his family member on 3/18/2022, where R1 slid from his chair onto the floor. Per incident report R1 stated the incident occurred two weeks prior. R1 also stated at the time of the incident he refused help from the two (2) staff that came to assist. S1 stated during interview that protocol is for staff to inform the director of the incident in a timely manner.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (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. A copy of the appeal rights and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/24/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240124152114

FACILITY NAME:PACIFICA SENIOR LIVING UNION CITYFACILITY NUMBER:
019200509
ADMINISTRATOR:ROBY, ROBERT BFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:110CENSUS: 57DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marie Lagasca-Cruz, Executive DirectorTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Resident sustained a fracture while in care
Staff did not provide resident showers according to the resident's Admission Agreement
Staff did not ensure that resident was adequately fed
Staff did not keep resident's room clean or sanitary
Facility call system was not accessible to resident
INVESTIGATION FINDINGS:
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On 12/6/2024 at 10:00am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Marie Lagasca-Cruz and explained the reason for the visit.

During the course of the investigation the Department conducted interviews with staff, witness, and obtained and reviewed records, including medical records from Kaiser of San Leandro for R1.

Allegation: Resident sustained a fracture while in care

W1 stated during interview that R1 did not lock one of the wheels on the wheelchair

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20240124152114
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 UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC9099.

and fell when trying to independently transfer from bed to wheelchair. Review of Kaiser of San Leandro medical records dated 3/19/2022, indicated R1 sustained a fracture to his right humerus bone while transferring from his wheelchair to his bed. At the time of admittance to the facility and at the time of the injury, R1 was independent and able to transfer between his bed and wheelchair. Based on record review, R1 was listed as ‘independent’ and did not require transfer assistance from and to bed from the wheelchair.

Allegation: Staff did not ensure that resident was adequately fed

W1 stated that R1 was able to wheel himself around but didn’t want to. R1 wanted staff to wheel him downstairs to the dining area. W1 stated there were times that staff would come to assist R1, but it was too early for R1 to eat. Department reviewed charting notes from facility that indicated R1 refused dinner several times due to R1 had food or snacks in his room. Per R1's assessment R1 required reminders for meals not to be escorted.

Allegation: Staff did not provide resident showers according to the resident's Admission Agreement

Based on interview with W1 showers were to be given to R1 Friday’s at 1pm and R1 would refuse if showers were not timely. W1 stated the facility was aware of this before R1’s admission. Review of admission agreement indicated facility will provide assistance with bathing. Review of R1's assessment dated 11/29/2021 indicated R1 required a one (1) person assist per week for bathing. Department did not

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20240124152114
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 UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 12/06/2024
NARRATIVE
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Continued from LIC9099C.

observe any documentation that was agreed upon between R1's responsible party and the facility that showers will be given at a specific time. Per S1 staff would try to accommodate R1's request for the time of shower but it was not always possible due to assisting other residents.

Allegation: Staff did not keep resident's room clean or sanitary

Based on initial interview with W1 staff did not keep resident’s room clean or sanitary. During interview with W1 on 12/2/2024, W1 stated there was not an issue with R1’s room being cleaned. W1 saw the housekeeper a few times while visiting.

Allegation: Facility call system was not accessible to resident

Based on interview with W1 the call pendent R1 was given was usually broken. W1 stated when the pendent wasn't working staff would come and take it, but wouldn't get it replaced for a couple of days. During interview with S1 if a pendent was not working or low battery the system will notify staff and a new pendent will be give. S1 stated the pendents can not be fixed. The facility keeps pendents available. S1 pulled a call log from the archives dated 3/13/2022 - 3/31/2022, which divulged R1 had used pendent six (6) times during that period. The dates the pendent was used was 3/13, 3/14 (2xs), 3/16, 3/17, and 3/18.

Based upon the interviews conducted and information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.


SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20240124152114
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 UNION CITY
FACILITY NUMBER: 019200509
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
87211(a)(1)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence... evidence by:
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Administrator submitted reporting and abuse training that was completed on 7/27/2024, to LPA during visit. Deficiency cleared during visit.
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This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above by notifying the responsible party, which poses a potential health and safety risk to 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6