019200509-7-14-2025-15-AS-BFOG-DKNR52-20250818124224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200509
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:08:49 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
06/10/2025 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20250610084817

FACILITY NAME:	PACIFICA SENIOR LIVING UNION CITY		FACILITY NUMBER:	019200509
ADMINISTRATOR:	LAGASCA-CRUZ, MARIE ANN		FACILITY TYPE:	740
ADDRESS:	33883 ALVARADO NILES RD		TELEPHONE:	(510) 489-3800
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	110	CENSUS: 54	DATE:	07/14/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Marie Lagasca- Cruz, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff mismanaged resident's medications.
Staff are not properly trained to administer medications.
Lack of supervision resulting in resident sustaining a fall.
Facility is not ensuring a staff is on duty on the premises overnight

INVESTIGATION FINDINGS:

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On 7/14/2025 at 9:45 am, Licensing Program Analysts (LPAs), K. Nguyen and P. Manalo arrived unannounced to deliver findings for the above allegations. LPAs met with Executive Director, Marie Lagasca- Cruz and explained the reason for the visit.

Allegation: Staff mismanaged resident's medications- UNSUBSTANTIATED
It was alleged that the Staff mismanaged residents’ medications. However, during the investigation, LPAs reviewed R1 Physician report, Admission orders, Identification and Emergency Information, R1 Medication Administration Record (MAR), R1 centrally ordered medication, and the destruction report shows that on May 5, 2024, R1 still had medication and was given to R1. On May 10, 2024, R1 medication was given to R1 family member. On May 26th, 2024, the facility made a refill to Omnicare Pharmacy, and Omnicare refilled R1 medication on 6/19/2024.

Report continued on LIC 9009c…

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250610084817

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: 07/14/2025

NARRATIVE

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Allegation: Staff are not properly trained to administer medications - UNSUBSTANTIATED

It was alleged that the Staff are not properly trained to administer medications. However, during the investigation, LPAs reviewed the Med Tech schedule for May, June, and July 2024. S2, S7, S8, and S9 were scheduled as Med Tech during May, June, and July 2024. The record reviewed shows that S2, S7, S8, and S9 have all completed their training on record.

Allegation: Lack of supervision resulting in resident sustaining a fall - UNSUBSTANTIATED

It was alleged that the facility lacks supervision, resulting in a resident sustaining a fall. During the investigation, LPAs reviewed the R2 physician report, R2 assessment, the time R2 moved in and after the sudden fall. At the time of the incident, R2 was receiving appropriate supervision according to the R2 assessment. R2 assessment dated 12/17/2023 – 5/23/2024 shows R2 ambulates independently. R2 had a sudden fall on 6/24/2024 facility updated R2's needs and services plan after the fall, dated 6/25/2024, indicated that R2 will be checked every two hours before and after bedtime on going.

Allegation: Facility is not ensuring a staff is on duty on the premises overnight- UNSUBSTANTIATED

It was alleged that the facility is not ensuring a staff in on duty on the premises overnight. During the investigation, LPAs reviewed the staff schedule for May 2024 to the current shows the facility has staff on duty on the premises overnight. LPAs conducted staff and resident interview confirmed that there are staff on duty on the premises overnight.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025

LIC9099 (FAS) - (06/04)

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