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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:15:39 PM

Document Has Been Signed on 10/14/2021 04:15 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:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Melody Lee- Allmond, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez arrived unannounced for the purpose of following up on an incident involving a self reported incident submitted to Community Care Licensing (CCL). On 9/28/21 an SOC341 was sent to CCL regarding R1 aggressive behavior towards R2 twice in the same day. Facility failed to ensure resident was accorded a safe environment being hit by R1 back to back. LPA requested documents and conducted interviews with staff and Administrator. LPA requested documents for both residents: Physician Report, Appraisal, and Care Notes. R1's Physician Report dated 6/5/21 states that R1 has aggressive behaviors. Current Care plan dated 6/22/20 for R1 does not address aggressive behavior. Administrator contacted police, CCL and Ombudsman. Administrator stated that R1 and R2 have had previous incidents and decided to move R1 to a different location in facility. Responsible party was notified and agreed for R1 to be moved.

During visit, LPA noticed another incident 9/17/21 when reviewing R1's Care Notes. R1 was aggressive towards R2. Facility failed to report 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, Administrator, Melody Lee-Allmond and appeals right given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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 10/14/2021 04:15 PM - It Cannot Be Edited


Created By: Karen Lopez On 10/14/2021 at 03:22 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.**This requirement is not met as evidenced by:
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Facility will submit a written plan to prevent R1 aggression with R2 and other residents and submit training for staff for this plan. Facility will update Care Plan for R1.
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Based on record review and interviews facility failed to ensure resident was accorded a safe environment being hit by R1 back to back.
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Type B
10/18/2021
Section Cited
CCR87211(a)(1)(d)

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87211(a)(1)(d) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. **This requirement is not met as evidence by:
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Facility will submit incident that occurred on 9/17/21 to CCL by 10/18/21.
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Based on record review and staff interview facility failed to report incident that threatened the safety or health of resident. This poses a potential health or 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:Bethany Moellers
LICENSING EVALUATOR NAME:Karen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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