<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 09/23/2021
Date Signed: 09/23/2021 03:02:13 PM

Document Has Been Signed on 09/23/2021 03:02 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:LEE-ALLMOND, MELODYFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 75CENSUS: 66DATE:
09/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH: Melody Lee-AllmondTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Lopez and Canela arrived unannounced for the purpose of following up on an incident involving a self reported incident submitted to Community Care Licensing (CCL). On 9/7/2021 a resident went AWOL from the facility. LPA met with Administrator, Melody Lee-Allmond and reviewed records. Physician's report indicates that the resident cannot be in the community without assistance from the staff. It was reported R1 went into another residents room, climbed over the air conditioning unit that was against the window, cut the screen with a key that was in his possession and climbed over the widow and got out. Vacaville Police department was notified and searched for the resident, it was reported the resident may have used some chairs that were in the parking lot yard of the facility to climb over the wall and exit the grounds.

Facility explained they have never had an incident were a resident has actually cut through the screen of a window to get out. All windows and screens have alarms to alert staff, but when the resident cut the screen the alarm was not able to alert staff. Facility conducted a check of all resident bedroom windows to ensure they are all in working condition and immediately removed any chairs from the parking area. Residents do not have any access to the facility parking lot, the resident gained access to this area when R1 broke the screen and climbed out. Facility moved the resident to a different unit where he would be more engaged to meet his needs and placed him on 15 minute checks until he became more familiar with this facility. R1 was said to be doing well, family and physician were notified of the incident.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with , Melody Lee-Allmond and appeals right given
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/23/2021 03:02 PM - It Cannot Be Edited


Created By: Karen Lopez On 09/23/2021 at 02:55 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2021
Section Cited
HSC
1569.312(d)

1
2
3
4
5
6
7
1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. Based on review of incident report and interview with Administrator, this requirement has not been met as evidence by:
1
2
3
4
5
6
7
CItation cleared during inspection. Conducted staff training and checked all windows. Will initiate 15 minute checks on all new resident admissions, instead of every 30 minute.
8
9
10
11
12
13
14
It was reported R1 went into another residents room, climbed over the air conditioning unit that was against the window, cut the screen with a key that was in his possession and climbed over the widow and got out. R1's physician report states R1 may not leave facility unassisted . This is a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Bethany Moellers
LICENSING EVALUATOR NAME:Karen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2