019200509-1-16-2025-15-AS-HHUL-DDENUS-20250130094646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 01/16/2025
Date Signed: 01/16/2025 07:19:04 PM

Unsubstantiated

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
09/25/2023 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230925101546

FACILITY NAME:	PACIFICA SENIOR LIVING UNION CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	ROBY, ROBERT B		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 60	DATE:	01/16/2025
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Marie Lagasca-Cruz, Executive Director		TIME COMPLETED:	07:20 PM

ALLEGATION(S):

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Staff does not respond to call button in a timely manner.
Facility does not have sufficient food available for their anytime menu.
Staff does not treat residents with dignity.
Staff would retaliate against residents who complaint of facility services.
Facility is not providing nutritional food resulting in resident loosing weight.
Insufficient staffing
Resident is paying for services that's not being provided.
Facility is not following resident's diet per doctor's order.

INVESTIGATION FINDINGS:

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On 1/16/2025 at 11:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver complaint findings for the allegations above. LPA met with Executive Director, Marie Lagasca-Cruz.

During the investigation, LPA interviewed 5 residents, 8 staff, witness, and complainant. LPA obtained and reviewed documents including admission agreement, emergency information, diet order form, care plan, physician's report, call button logs, monthly bills, and resident detail ledger.

Staff does not respond to call button in a timely manner.
Majority of the call button logs were missing the response time. Interview with residents revealed that staff respond to call button timely. Interview with staff indicated that staff would respond to call button within 10-15 minutes. S6 stated that sometimes caregivers would forget to clear the call after assisting the resident. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 3

Control Number 15-AS-20230925101546

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: 01/16/2025

NARRATIVE

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Facility does not have sufficient food available for their anytime menu.
Interview with residents revealed that they are able to order from the "Always Available Menu". Interview with staff indicated that sometimes food distributors would be out of stock on certain food items on that menu. LPA observed facility have sufficient perishable and nonperishable items available.

Staff does not treat residents with dignity.
Interview with residents and staff revealed that staff treat residents well and are friendly to residents. Residents stated they have not witness staff mistreat residents.

Staff would retaliate against residents who complaint of facility services.
Interview with residents revealed that staff did not retaliate against residents. Interview with staff indicated they have not witness staff retaliate against residents and would treat residents the same.

Facility is not providing nutritional food resulting in resident loosing weight.
Interview with staff indicated the facility provides nutritional foods to residents and was not aware any residents loose weight due to poor nutrition. There was a lack of information provided regarding the resident who loose weight due to not provided enough nutritional foods.

Insufficient staffing
Interview with staff indicated the facility has sufficient staffing which includes 2-3 staff for morning and afternoon shift, and 2 staff for night shift. Interview with residents revealed that majority of residents felt the facility had enough staff.

Resident is paying for services that's not being provided.
R1's care plan indicated that R1 needed standby assist with bathing, partial assist with transfers, escort R1 to meals/activities, and special diet which was a level 4 care. However, R1's detail ledger revealed that R1 was charged for level 2 care which did not include most of the services in R1's care plan.
(Continue on LIC9099C...)

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230925101546

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: 01/16/2025

NARRATIVE

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Facility is not following resident's diet per doctor's order.
R1 had a diet order form which indicated that R1 is on a mechanical soft diet. Interview with staff revealed that residents with special diets are identified in the kitchen area. S3 stated that staff have provided mechanical soft meals for R1, but R1 didn't want the food and sent it back.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC9099 (FAS) - (06/04)

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