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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:37:16 PM

Document Has Been Signed on 01/09/2025 12:37 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/
DIRECTOR:		LAGASCA-CRUZ, MARIE ANNFACILITY TYPE:
740
ADDRESS:33883 ALVARADO NILES RDTELEPHONE:
(510) 489-3800
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 110CENSUS: 59DATE:
01/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Marie Lagasca-Cruz/Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On this day, 1/09/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management visit resulting from a complaint (Complaint Control # 15-AS-20230209091605) investigated by the Department. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the purpose of visit.

During investigation, the Resident Services Director (RSD) stated she advised R1’s sister via telephone on 1/14/23 that R1 was not well and was going to send her to the hospital. Between 1/14/23 through 1/21/23, R1 was weak, refused to eat on some days, and barely able to stand up. Other days, R1 was responsive and requested foods but ate very little. During RSD’s interview, RSD stated R1’s sister declined to have R1 sent to the hospital, but RSD did not agree. Previous Assistant Executive Director stated staff are to report concerns to the resident's doctor when families decline. There was no communication with R1’s doctor for the date of 1/14/2023, and R1 was not sent to the hospital until 1/21/2023 – a week later.

Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with the ED.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 01/09/2025 12:37 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 01/09/2025 at 11:45 AM
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: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
87465(a)(2)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility......... (2) The licensee shall provide assistance in meeting necessary medical and dental needs……...
-This requirement is not met as evidenced by:
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Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 1/10/25.
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-Based on records review and interviews, the licensee did not comply with the section in not seeking immediate medical assistance for resident (R1) which posed an immediate risk to the health risk to person 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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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