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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200509
Report Date: 07/14/2025
Date Signed: 07/14/2025 04:42:54 PM

Document Has Been Signed on 07/14/2025 04:42 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
OAKLAND ASC, 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: 54DATE:
07/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marie Lagasca-Cruz, Executive Director TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 07/14/2025 at 10:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Executive Director, Marie Lagasca-Cruz, and explained the purpose of the visit.

LPA toured the facility inside and out including but not limited to 7 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 118.4, 112.9, 111.3, 116.6, 115, and 114.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Alarm System Inspection was last conducted on 04/02/2025. Fire extinguisher was last serviced on 11/29/2024. Emergency Disaster Plan was last posted on 10/22/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/24/2025.

At 12:46 PM, LPA reviewed 6 residents records. At 1:30 PM, LPA reviewed 6 staff records and 6 of 6 are associated to the facility. At 2:30 PM, LPA reviewed two sample of residents’ medications.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/14/2025 04:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 07/14/2025 at 02:49 PM
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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having unlocked prescription of topical cream in R1's room which poses an immediate safety risk to persons in care.
POC Due Date: 07/15/2025
Plan of Correction
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The Executive Director agrees to lock the ointment and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PACIFICA SENIOR LIVING UNION CITY
FACILITY NUMBER: 019200509
VISIT DATE: 07/14/2025
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 07/22/2025:

Liability Insurance
Administrator Certificate

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:46 AM, LPA observed unlocked topical cream in R1's room.

At 12:00 PM, LPA observed food not properly stored and labeled.

At 3:29 PM, record review revealed that the facility did not have an updated physician's report for residents.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
Page: 9 of 9
Document Has Been Signed on 07/14/2025 04:42 PM - It Cannot Be Edited


Created By: Patricia Manalo On 07/14/2025 at 03:41 PM
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: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not properly storing and labeling food which poses a potential health and safety risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The Administrator will self-certity the regulation and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having updated medical assessment for residents in care which poses a potential health and safety risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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The Executive Director agrees to obtain medical assessments for R1, R3, R4, R5, and R6 and send proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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