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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200513
Report Date: 12/28/2022
Date Signed: 12/28/2022 03:29:31 PM

Substantiated


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
06/29/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200629162751
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: 111DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not seek emergency medical services for resident
INVESTIGATION FINDINGS:
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On 12/28/2022 at 1:50PM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes conducted an unannounced visit to deliver complaint findings for the above allegation. LPA met with Anthony Garcia, Executive Director (ED) and explained purpose of the visit.

During the course of the investigation, the Department conducted interviews with staff, witnesses, residents, obtained and reviewed records. On the allegation staff did not seek emergency medical services for resident, during interviews and record reviews it indicated R1 fell at approximately 03:20AM. Based on review of hospice records Resident 1 (R1) had an unwitnessed fall on 6/27/2020 and was found on the floor outside of her room by staff. Interview with the Hospice nurse indicated the nurse was not there at the time of the fall but was only informed by R1’s family. The hospice nurse stated that

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
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 6
Control Number 15-AS-20200629162751
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 OAKLAND
FACILITY NUMBER: 019200513
VISIT DATE: 12/28/2022
NARRATIVE
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Continued from LIC9099.

the facility never reported the fall. The Reporting Party (RP) stated during interview that the facility never called 9-1-1 after the fall. The RP also stated that RP called R1’s doctor and had a Mobil x-ray conducted. The x-ray showed that R1 had a broken femur, and the facility did not call 9-1-1 until 08:30PM. During record review of Alta Bates Summit-Merritt discharge summary notes dated 07/02/2020, notes indicate that R1 was x-rayed on 6/27/2020 at 11:03PM and was seen/examined on 06/28/2020. Even though medical attention was given to R1 it was not done in a timely manner, therefore, based on the investigation the allegation is deemed Substantiated.

Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20200629162751
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 OAKLAND
FACILITY NUMBER: 019200513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited
CCR
87465(g)
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87465 (g) The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidence by:
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Administrator agrees to have an authorized vendor conduct in-service staff retraining on timely addressing residents’ medical needs. Administrator agrees to submit completed staff retraining certifications to CCLD by POC date.
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Based on investigation the Licensee did not comply with the section cited above in telephoning 9-1-1 immediately for an injury, which poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/29/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200629162751

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: 111DATE:
12/28/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Anthony Garcia, Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained a broken left femur due to negligence

Resident was assaulted by another resident due to lack of supervision.

Resident sustained unexplained bruises
INVESTIGATION FINDINGS:
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On 12/28/2022 at 1:50PM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes conducted an unannounced visit to deliver complaint findings for the above allegations. LPA met with Anthony Garcia, Executive Director (ED) and explained purpose of the visit. Based on the investigation the above three (3) allegations are deemed Unsubstantiated.

During the course of the investigation, the Department conducted interviews with staff, witnesses, residents, obtained and reviewed records. Based on interviews and record review Resident 1 (R1) was admitted into Assisted Living on 2/15/2020 and then to memory care on 5/30/2020 as a result of requiring a higher level of care. Based on record review and interviews, it indicates that R1 fell on 6/27/2020 at approximately 3:20AM, staff found
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20200629162751
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 OAKLAND
FACILITY NUMBER: 019200513
VISIT DATE: 12/28/2022
NARRATIVE
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Continued from LIC9099.

R1 on the floor. Documentation for R1 also indicates, R1 sustained approximately five additional falls despite having various one-to-one private caregivers. Staff stated during interviews that memory care clients are checked every two hours. Staff that were interviewed all stated R1 was a wanderer and would often forget to use her walker or would leave it in multiple places. Staff also stated during interviews that memory care clients are checked every two hours. Reporting Party (RP) stated that on 6/27/2020 R1 was found on the floor by staff at approximately 3:20AM. (RP) contacted the on-call doctor prior to R1 being transported to the Emergency Department (ED) and x-rays showed R1 sustained a left femur fracture.

During the course of the investigation, including file review, the Department observed that after R1 transitioned to the memory care unit on 5/30/2020, R1 continued to sustain injuries from multiple falls. Record review indicated that it was documented in Hospice Care’s initial assessment of R1 that R1 was never to be left unsupervised. Records also indicated that the family provided a one-to-one caregiver. The caregiver along with facility staff indicates R1 was not left unsupervised. Review of R1’s unusual incident reports that occurred between 5/24/2020 to 6/15/2020, it was documented and noted that medical treatment was not necessary as R1 sustained bruising and did not complain of any pain. Review of the facility’s unusual incident reports and staff charting indicates that R1 had a history of falls.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20200629162751
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 OAKLAND
FACILITY NUMBER: 019200513
VISIT DATE: 12/28/2022
NARRATIVE
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Continued from LIC9099C.

Staff that were interviewed all stated R1 was a wanderer.
Record review and interviews indicated that on 6/17/2020 R1 wandered into another resident’s room where she was found on the floor by the RP. R1’s one-on-one private companion was cancelled on 6/7/2020 and restarted on 6/22/2020, thus R1 did not have a one-on-one companion at the time of the incident. Record review indicated that staff responded when they heard Resident 2 (RP 2) screaming loudly once, therefore staff was in the general area and was able to respond in a timely manner at the time of the incident.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6