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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803645
Report Date: 11/05/2024
Date Signed: 11/05/2024 04:26:54 PM

Document Has Been Signed on 11/05/2024 04:26 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR/
DIRECTOR:		MCGRANAHAN, JULIETFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 75CENSUS: 63DATE:
11/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Executive Director, Juliet McGranahan, and Resident Care Director, Lorena Madrigal TIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a 1-Year Required Visit and met with Executive Director/Administrator, Juliet McGranahan, and Resident Care Director, Lorena Madrigal Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 75 non-ambulatory residents of which 10 can be bedridden. Facility has an approved hospice waiver for 15 individuals and has approval for a secured perimeter. Upon arrival, LPA was informed that there were 63 Residents in care and 20 staff members on-site.

LPA conducted a walk-though of the facility with Resident Care Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is comprised of 5 separate houses for residents, 1 office building, and facility kitchen. Each house has 13 resident rooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to Residents. LPA observed that 4 of 10 sinks accessible to residents were out of compliance with Title 22 Regulations, measuring at 147.2F, 128.6F, 125.7F, and 138.2F (deficiency cited, LIC809D, regulation 87303(e)(2)).

LPA reviewed staff files, resident files and resident medication. During staff file review, LPA observed 6 of 8 staff files had current First Aid and CPR certification (Technical Violation issued, LIC9102, Regulation 87411(c)(1)). LPA also observed that 8 of 8 staff files did not have annual 2024 training conducted as required by Health and Safety Code (deficiency cited, LIC809D, H&S Code 1569.625(b)(2)). During resident file review, LPA observed that 1 of 5 residents did not have an updated Physician's Report (LIC602) as required (technical violation issued, LIC9102, regulation 87705(c)(5)). During medication review, LPA observed that 4 of 10 resident medication was not centrally stored and logged as required (deficiency cited, LIC809D, regulation 87465(h)).

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PACIFICA SENIOR LIVING VACAVILLE
FACILITY NUMBER: 486803645
VISIT DATE: 11/05/2024
NARRATIVE
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Continued from LIC809

Administrator's Certificate for Juliet McGranahan (6071164740) was current with an expiration date of 07/10/2026.

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610E)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 12/06/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director and Resident Care Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 11/05/2024 04:26 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/05/2024 at 03:42 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
, 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that 4 of 8 staff members received their annual 20 hours training as required by Health and Safety Code. This poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 11/17/2024
Plan of Correction
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Licensee to submit a written plan outlining how they will ensure all staff on site will obtain their annual 20 hour training as required by Health and Safety Code by POC due date of 11/17/2024. Licensee to submit proof of completed annual training for identified staff members by 12/06/2024.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that 4 of 10 resident medications were documented and centrally stored as required. This poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 11/17/2024
Plan of Correction
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Licensee to conduct a medication audit and conduct an in-service training for all medication technicians reviewing how to centrally store medications. Licensee to provide CCL an update on when audit and in-service training will be scheduled by POC due date of 11/17/2024. In-Service Training to include: Date of Training, Training Topics, Job Role, Staff Names and Signatures. In-service training to be submitted by POC due date of 12/06/2024.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 11/05/2024 04:26 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 11/05/2024 at 03:44 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
, 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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, the Licensee did not comply with the section cited above. 4 of 10 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring at 147.2F, 128.6F, 125.7F, and 138.2F. This poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 11/17/2024
Plan of Correction
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Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks in each house starting on 11/06/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 11/17/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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