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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 10/21/2022
Date Signed: 10/21/2022 09:59:07 AM

Document Has Been Signed on 10/21/2022 09:59 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:JEFFERY GOLLIHARFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 75CENSUS: 55DATE:
10/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Jeffery GolliharTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Pacifica Senior Living Vacaville for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Jeffery Gollihar, and was granted access into the facility.

During the course of the investigation that was initiated on July 21, 2022, LPA reviewed documents and conducted interviews with staff and witnesses. LPA learned that R1 had a change of condition which was documented on a paper that was provided by the outside agency nurse that assessed R1 in Mid-July 2022. However, facility did not document the change of condition on an LIC 602/Physicians Report nor was an updated LIC 602/Physicians Report retained in the resident records (See LIC 809D).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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 10/21/2022 09:59 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 10/21/2022 at 07:29 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited
CCR
87506(b)(10)

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87506(b)(10) Resident Records:

(b) Each resident’s record shall contain at least the following information:

(10): Reports of the medical assessment specified in Section 87458,
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Licensee shall retrain all staff on admissions, reappraisals and record keeping. Licensee shall provide a self-certification and the understanding of this regulation. In addition, Licensee shall provide a written statement on how future compliance will be met.
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Medical Assessment, and of any special problems or precautions.

This requirement was not met as evidenced by:

Based off of observation of facility records and interviews with staff members. LPA learned and identified that R1 did have a change of condition, and was not documented on a LIC 602/Physicians Report nor retained in resident records. This is a potential health, safety and personal rights risk to the residents in care.
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Administrator requested to have an extension of the Plan of Correction (POC). POC extension granted for October 31, 2022.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022


LIC809 (FAS) - (06/04)
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