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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200513
Report Date: 02/24/2023
Date Signed: 02/25/2023 09:42:49 AM

Document Has Been Signed on 02/25/2023 09:42 AM - 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:GARCIA, ANTHONYFACILITY TYPE:
740
ADDRESS:2330, 2350, 2361 E 29TH STTELEPHONE:
(510) 534-3637
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 197CENSUS: 90DATE:
02/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Anthony Garcia/Executive DirectorTIME COMPLETED:
06:35 PM
NARRATIVE
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While conducting investigation of a complaint (15-AS-20211123105807) and upon request for staff file, LPA learned that files were not available.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Anthony Garcia.

Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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 02/25/2023 09:42 AM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/24/2023 at 05:26 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: 02/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87412(f)

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87412 Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
-This requierment is not met as evodenced by:
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Executive Director to read the Regulation, and self-certify that records wiill be made reacily available for inspection. Self-certification to be submitted by 3/03/23..
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-Based on interview, the licensee did not comply with the above for not having staff file available for review.
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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