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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803645
Report Date: 01/03/2025
Date Signed: 01/03/2025 03:17:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20240923174728
FACILITY NAME:PACIFICA SENIOR LIVING VACAVILLEFACILITY NUMBER:
486803645
ADMINISTRATOR:MCGRANAHAN, JULIETFACILITY TYPE:
740
ADDRESS:431 NUT TREE ROADTELEPHONE:
(707) 449-1350
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 65DATE:
01/03/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Resident Care Director, Lorena MadrigalTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure resident’s incontinence needs were met
INVESTIGATION FINDINGS:
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At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Resident Care Director, Lorena Madrigal.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not ensure resident’s incontinence needs were met." Report received on 09/23/2024 stated that facility staff has shown neglect by double briefing residents to save time when working on the floor.

LPA conducted staff interviews. 4 of 6 staff interviews conducted stated that residents have been observed to be double briefed or to be wearing two incontinence briefs at a time. Photos provided to LPA showed residents wearing two incontinence briefs at a time.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20240923174728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/03/2025
NARRATIVE
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Continued from LIC9099

Facility correspondence between management and facility staff showed that double briefing had occurred at the facility. LPA was provided with copies of incontinence care in-service training that was conducted for all direct care staff on 10/10/2024.

Based on interviews conducted and observations made, this allegation is Substantiated.
A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Resident Care Director. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240923174728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights: (4) to care, supervision, and services that meet their
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Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include:
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individual needs...This requirement was not met as evidenced by: Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontincence care needs were met. This is an immediate health and safety risk to residents in care.
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Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3