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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 10/11/2021
Date Signed: 10/11/2021 05:27:22 PM

Document Has Been Signed on 10/11/2021 05:27 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PACIFICA SENIOR LIVING OAKLANDFACILITY NUMBER:
019200513
ADMINISTRATOR:AMANDA M DOMINGUEZ NORTHFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 197CENSUS: 112DATE:
10/11/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Ruth OconTIME COMPLETED:
05:40 PM
NARRATIVE
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On 10/11/21 starting at 3:25 pm Licensing Program Analysts (LPAs) L. Francisco and G. Clark conducted a health and safety check as a result of department receiving a priority 1 complaint.

LPAs toured facility including but not limited to the apartments, bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 117, 123 and 96 degrees F in 3 bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/20/21. There are no accessible bodies of water observed.

The following deficiencies were observed:
  • at 3:35 pm the hot water temperature was maintained at 123 degrees F.
  • at 3:50 pm the hot water temperature in common bathroom was maintained at 96 degrees F.
  • at 3:55 pm LPAs observed a dresser blocking the exit door in the memory care building


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 Failure to correct deficiencies by POC date may result in additional Civil Penalties.

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Exit interview conducted Resident Care Director, Joann Nisperos. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Lizette Francisco
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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Document Has Been Signed on 10/11/2021 05:27 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Lizette Francisco On 10/11/2021 at 04:51 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 OAKLAND
FACILITY NUMBER: 019200513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/12/2021
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation
(e)Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents...Hot water temperature controls shall be maintained ... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Administrator will maintain hot water temperature between 105 to 120 degrees F and submit a self-certification letter to CCL by POC date.
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This requirement is not met as evidenced by: Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed hot water temperature maintained at 123 and 96 degrees F which poses an immediate health and safety risk to residents in care.
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Under Appeal
Type A
10/12/2021
Section Cited
CCR87307(d)(6)

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Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement was not met as evidenced by:
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Administrator will remove dresser and submit a photo to CCL by POC date.

In addition, Administrator will review regulation and conduct training with staff and submit a copy of training to CCL by 10/29/2021
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Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed a dresser blocking the exit in the memory care building which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Lizette Francisco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021


LIC809 (FAS) - (06/04)
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