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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:56:51 PM

Document Has Been Signed on 06/23/2022 02:56 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 62DATE:
06/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Melody Lee-AllmondTIME COMPLETED:
03:05 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
At approximately 2:35PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Melody Lee-Allmond. The purpose of this Case Management Visit is to follow up on multiple self-reported incident reports submitted to Community Care Licensing (CCL) by this facility.

LPA discussed with Administrator an incident that occurred on 5/04/22. Report states that Resident 1 (R1) was observed by Medication Technician and Nurse to be unresponsive to verbal and physical stimuli. Facility called Emergency Personnel and notified R1's Responsible Party and Physician. Report states that R1 returned to facility on 5/06/22 with diagnosis of Urinary Tract Infection and was placed on Antibiotics. During intake of resident, Medication Technician observed bruising on R1. Facility notified Responsible Party and Physician of R1's return to community.

Per conversation with Administrator, R1 was placed on alert charting after returning to community. Bruises were noted by facility.

LPA discussed with Administrator an incident that occurred on 5/11/22. Report states that Resident 2 (R2) had a fall and complained of pain. Nurse was called to assess R2. Facility called Emergency Personnel and notified R2's Responsible Party and Physician. Community was notified by Emergency Room that R2 sustained a hairline fracture.

Per conversation with Administrator, R2 is back in facility and was placed on alert charting. Responsible Party declined for R2 to receive surgery treatment for fracture.

Continued on LIC 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
VISIT DATE: 06/23/2022
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
26
27
28
29
30
31
32
Continued from LIC-809

LPA and Administrator discussed an SOC-341 that was submitted to CCL on 6/22/22. Report states that Staff observed R1 and R3 out on patio. Staff observed R3 to be agitated and pushed R1. R1 lost their balance and fell. Staff responded. R1 was observed to have mouth bleeding and complained of pain. Facility called Emergency Personnel and notified R1's Responsible Party and Physician. Report stated that R1 required surgery.

Per conversation with Administrator, R3 is being assessed by their physician for new medication due to aggressive behaviors. Medical Personnel and Facility are discussing R1's discharge placement for Rehab. Administrator stated that Physician has been visiting frequently to address behaviors.

No Deficiencies cited during this inspection.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2