Inspection Reports for
Pacifica Senior Living Union City

The complaint included allegations of staff mismanaging resident medications, improper staff training for medication administration, lack of supervision resulting in a resident fall, and failure to ensure overnight staff presence. All allegations were investigated and found unsubstantiated.

All allegations were found to be unsubstantiated after review of relevant records, staff schedules, and interviews. The investigation concluded that medication management, staff training, supervision, and overnight staffing met regulatory requirements.

The complaint investigation addressed allegations of questionable death, failure to assist residents with bathing, residents left in soiled clothing, lack of clean clothing, and failure to assist with medication refills. After review of records, interviews with staff, family members, and former executive director, and examination of schedules and documentation, the allegations were found unsubstantiated.

Based on interviews, record reviews, and observations, all five allegations were closed as unsubstantiated due to insufficient evidence to prove violations occurred. No deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included unexplained bruising of a resident, residents not provided pendants, and lack of an administrator during operating hours. The Licensing Program Analyst reviewed medical records, facility documents, and conducted interviews with staff and residents. The evidence did not support the allegations, and the complaint was closed as unsubstantiated.

The investigation found no substantiated evidence to support the allegations. Documentation and interviews indicated no unexplained bruising, pendants were provided to residents in Assisted Living but not Memory Care as per facility policy, and the facility always had an administrator available during hours of operation. No deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included delayed staff response to call buttons, insufficient food availability, staff mistreatment and retaliation, poor nutrition causing weight loss, insufficient staffing, improper billing for services, and failure to follow diet orders. Interviews and document reviews did not support these allegations.

The investigation found no substantiated violations; staff generally responded timely to call buttons, sufficient food was available, residents were treated with dignity, no retaliation was observed, nutritional food was provided, staffing was sufficient, and diet orders were followed. However, one resident was charged for a lower level of care than indicated in their care plan.

The allegation that the facility charged a resident for services not provided was investigated and found unsubstantiated due to lack of preponderance of evidence.

The investigation found the allegation to be unsubstantiated after reviewing billing records and interviewing staff. The facility dropped all charges from the responsible party, confirming that all charged services were correct.

The Licensing Program Analyst found no deficiencies during the visit. The incident involved a resident who walked off from his wife's apartment, which was a new behavior, and staff promptly searched and found the resident near a senior center. The care plan was updated accordingly.

The allegation of sexual abuse was investigated and found unsubstantiated. The resident involved did not recall the event, and staff and a police officer noted the resident may be hallucinating due to medication and memory decline.

The investigation included interviews with staff and a resident, and review of relevant records. The allegation of sexual abuse was found to be unsubstantiated due to lack of preponderance of evidence.

The Executive Director confirmed that staff S1 had not been at the facility since May 16, 2024, and that S1 was terminated from the facility. The immediate exclusion order was explained and provided to the Executive Director.

No deficiency was noted during the visit. The Licensing Program Analyst reviewed Resident 1's medical and service records and interviewed staff and the resident.

The complaint alleged that staff did not safeguard a resident's personal belongings, specifically broken eyeglasses. The facility was found not responsible for the damage based on record review and interviews.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated.

The investigation found that Resident 2 is ambulatory and independent with activities of daily living (ADLs), requiring only cueing or reminders for tasks such as brushing teeth. Staff would provide the toothbrush but were not allowed to brush Resident 2's teeth. No deficiencies were noted during this visit.

The facility was found to have adequate infection control measures including proper PPE use, sufficient food supply, universal screening, and posted hygiene protocols. No deficiencies were cited during the visit.

The Licensing Program Analyst requested documents for Resident 1 including Physician's Report, Needs and Services Plan, and Incident Reports for January and February 2021. A copy of the report was provided to the Director via email.