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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 05/29/2025
Date Signed: 05/29/2025 12:08:16 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
11/22/2023 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20231122143232
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: 52DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marie Lagasca-Cruz/Executive DirectorTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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-Questionable death.
-Staff are not assisting residents with bathing needs.
-Residents are left in soiled clothing for an extended period of time.
-Staff are not ensuring that residents have clean clothing.
-Staff are not assisting residents with refilling their prescriptions.
INVESTIGATION FINDINGS:
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On this day, May 29, 2025, at 11:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Marie Lagasca-Cruz, and informed the reason for visit.

During the course of investigation, the Department reviewed residents’ records and obtained copies of including but not limited to the following documents: LIC601 Identification and Emergency Information; LIC602A Physician's Report; doctor's orders of medications; LIC622 Centrally Stored Medication and Destruction Records; Medication Administration Records; shower schedules; hospice record; death certificate.


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

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
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 4
Control Number 15-AS-20231122143232
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: 05/29/2025
NARRATIVE
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Page 2

LPA obtained copies of staff schedules, LIC501 Personnel Records and resident roster. LPA also interviewed the following: staff (S1, S2) and former Executive Director (FED) on 11/28/23; resident’s family member (W1) on 12/05/23; R1 and R3’s family member (FM1) and staff (S3 and S4) on 5/27/25.

Allegation: Questionable death.
It was reported that resident (R1) passed away on 11/19/23 because the facility did not seek timely medical assistance.

S1 stated when she went to R1’s room sometime between 11/06/23 and 11/08/23 and observed R1 pale and not responsive, she called 9-11. R1 was sent out and diagnosed with infection. Records confirmed R1 was sent out to the hospital. Records also showed R1 was placed on hospice on 11/10/23 with terminal diagnosis of cerebrovascular disease. Death certificate showed immediate cause of death as cerebrovascular disease, Parkinson’s disease, adult failure to thrive and no other significant conditions contributing to R1’s death. Based on information gathered, the allegation is closed as unsubstantiated.

Allegation: Staff are not assisting residents with bathing needs.
S1 stated that R2 has not been showered for a month. S2 indicated that bathing is included in the resident’s Care Plan and the frequency depends on the Care Plan. S3 and S4 stated they give bath to residents 2 times per week. FM1 stated she visited R1 and R3 when they were at the facility and stated R1 and R3 were bathe 2 times per week.

Review of bathing schedules showed R1 on the list on a once-a-week schedule. R2 was listed on twice-a- week schedule. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated. .......continued on 9099C (page 3)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20231122143232
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: 05/29/2025
NARRATIVE
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Page 3

Allegation: Residents are left in soiled clothing for an extended period of time.
S1 stated that R2 was often left in soiled clothing for hours and not provided care due to R2 has been deemed by the caregivers as a difficult resident. S1 also stated that when she was assigned to Memory Care, she observed R2 wore the same clothes from previous day. S2, S3 and S4 stated residents’ clothing are changed every day. FED stated that it was never brought to his attention about the issue.
FM1 stated she never observed R1 and R3 in soiled/uncleaned clothes. W1 also stated not observing her mother in soiled clothing and when her mother felt wet, the caregiver came right away. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated.

Allegation: Staff are not ensuring that residents have clean clothing.
S1 stated there were times she observed R2 not wearing undergarment and socks. S1 further stated that when she asked the caregivers, she was told that R2 did not have clean clothes. S2 stated there was never an incident where resident run out of clean clothing. S2 further stated that if they see residents do not have enough for the week, they communicate. S3 and S4 stated that residents assigned to them never run out of clean clothes. FED stated the issue was never brought to his attention. FM1 and W1 stated their love one never run out of clean clothes. LPA was not able to interview R1 and R3 due to these residents were no longer at the facility when complaint was received. Due R2’s medical diagnosis, LPA was also unable to obtain information. LPA tried to reach R2’s responsible person but was unsuccessful. Therefore, the allegation is unsubstantiated.

......continued on 9099C (page 4)
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20231122143232
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: 05/29/2025
NARRATIVE
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Page 4

Allegation: Staff are not assisting residents with refilling their prescriptions.
S1 stated that R2 and other residents were missing medications because the medications were not refilled. S1 further stated that according to S5, R2 was not receiving medications because R2's responsible person (FM2) was not picking up the phone when they call. S2 stated the med-techs are in-charge of medications including refills. S2 further stated that the cycle of med refills is every 2nd of the month to ensure residents never run out of medications and that 15 days before medications run out, the med-tech take care of refills. S3 and S4 stated the med-techs are in-charge of medications. W1 stated her mother never run out of medications and that the staff were very good in calling and telling her when her mother is running out of medications and refills were done right away. LPA tried but unable to obtain information from S5 and FM2. Therefore, the allegation is unsubstantiated.

Based on interviews and records review, the five allegations are 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: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4