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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 04/24/2025
Date Signed: 04/24/2025 05:43:58 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
06/07/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220607084551
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: 54DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marie Lagasca/Executive DirectorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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-Resident sustained unexplained bruising while in care.

-Resident is not provided a pendant.

-Facility does not have an administrator during hours of operation.
INVESTIGATION FINDINGS:
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On this day, 4/24/25, at 2:30 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Sales Director Tristan Reyes and Resident Services Coordinator Popotafea Aumua. Executive Director (ED) Marie Lagasca arrived at around 3:10 p.m. LPA informed the reason for visit.

During the course of investigation, LPA obtained copies of resident rosters and staff schedule, and conducted interviews. LPA also obtained copies of the following residents' documents: LIC601 Indentification and Emergency Information; Admission Agreements; LIC602A Physician's Reports; Residents' Assessments; Unusual Incident Report (UIR); facility notes and Narrative Charting for resident. LPA interviewed the following: staff (S1 and S2) on 2/13/23; staff (S3, S4 and ED) on 4/24/25; residents (R3 and R4) on 4/24/25

....continued on 9099C (page 2)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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-20220607084551
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: 04/24/2025
NARRATIVE
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Page 2

Allegation: Resident (R1) sustained unexplained bruising while in care.
R1's family member (FM) stated that on 5/10/22, FM reached out to the assistant director regarding an incident where R1 ended up crying at the end of R1's shower and the next day the nurse found bruising on R1's shoulder and arms. LPA reviewed the documents from Pine Park Health, a third party that provides medical services to the residents in the facility. Pine Park's records and visit notes for R1 from 1/26/22 to 6/22/22 didn't show any note indicating R1 had bruising. Facility's Narrative Charting of communication with R1's responsible person and R2 (R1's husband) for R1 for 1/10/22, 1/13/22, 1/29/22, 2/16/22, 2/22/22, 3/14/22, 3/30/22 and 6/15/22 had no information pertaining to bruising. There's no UIR regarding bruising. LPA could not interview R1 and R2 since they were longer at the facility.

Based on information gathered and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated.

Allegation: Residents not provided a pendant.
FM stated that R1 and R2 did not have pendant for 4 days because it was broken.

S1 and S2 stated R1 and R2 had pendant. S1 stated she does not recall R1 and R2 not having pendant for days. S2 stated it's always R2 who pressed the pendant when help was needed.

S3 and S4 stated the residents in Assisted Living (AL) are provided pendants but not the residents in Memory Care (MC). When pendant is not working or broken, it is replaced same day. These statements were confirmed by LPA with ED. ED stated only residents in AL are provided pendant. ED further stated that residents in MC are not given pendants because staff do more supervision. If the pendant is broken, it is replaced the same day. The facility has at least 6 extra pendants.



.....continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220607084551
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: 04/24/2025
NARRATIVE
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Page 3

R3 and R4 stated they have pendants. R3 stated she seldom use hers while R4 stated the pendant is working and the staff check it regularly.

Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated.

Allegation: Facility does not have an administrator during hours of operation.
When LPA conducted an initial complaint visit on 6/24/22, LPA met with interim Administrator Mandy Taylor. Ms. Taylor has valid administrator certificate.

S1 stated never was a time where facility has no executive director (ED)/administrator. If the ED quits and the corporate is in the process of hiring, the Regional Director serves as interim administrator. S2 stated the facility has always administrator to talk to.

R3 and R4 stated there's always administrator and staff available.

Based on information obtained and LPA unable to obtain information from R1 and R2, the allegation is closed as unsubstantiated.

A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3