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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601046
Report Date: 11/06/2024
Date Signed: 11/06/2024 01:25:02 PM

Document Has Been Signed on 11/06/2024 01:25 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR/
DIRECTOR:		NICKOLAI, KARENFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 60CENSUS: 52DATE:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Resident Services Director, Mary Anne RodriguezTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On November 6, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to complaint # 14-AS-20240424121204. LPA met with Resident Services Director, Maryanne Rodriguez and explained the purpose of the visit.

During the complaint investigation, the Department discovered that Staff #1 (S1) was not fingerprint cleared and/or associated to the facility. Based on the interview conducted with S1, he/she has been working at the facility for several months and his/her duties consists of contacting families, doctors, communicating with nurses, administering medication to residents, assessing vital signs, tracking resident's medical information and assisting residents with activities of daily living.

Based on S1's file reviewed, S1 was hired on 1/19/24 as a medication technician. LPA reviewed S1's file and did not observe S1's fingerprints in file. LPA did not observe any association paperwork in S1's file. LPA requested the documents from Resident Services Director and the Business Office Manager at the time of the visit, however neither was able to provide it to LPA.

A civil penalty of $500 is being assessed during the visit. $100 a day x 5 days = $500.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the Resident Services Director and a copy is provided with appeal rights. A copy of civil penalty is provided to the Resident Services Director along with the appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 01:25 PM - It Cannot Be Edited


Created By: Komal Charitra On 11/06/2024 at 12:51 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or...

This requirement was not met as evidenced by:
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S1 no longer is employed at the facility, however licensee/administrator shall conduct an audit to ensure all staff that are currently employed at the building have fingerprint clearance and are associated to the facility
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Based on filed reviewed, LPA was unable to locate S1's fingerprint clearance and facility association documentation for S1. In addition, the resident care director and the business office manager were unable to provide LPA with confirmation or documentation of S1's fingerprint clearance and/or S1's facility association documentation
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A civil penalty of $500 is being issued during the visit today; $100 a day for 5 days = $500.

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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:April Cowan
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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