Inspection Reports for Pacifica Senior Living Union City

An unannounced complaint investigation visit was conducted in response to allegations received on 2025-06-10 regarding medication mismanagement, staff training, supervision related to a resident fall, and overnight staff presence.

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 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.

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The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

The facility was found to have deficiencies including unlocked topical cream posing immediate safety risk, improperly stored and labeled food posing potential health risk, and lack of updated physician reports for residents. Safety equipment and environmental conditions were generally adequate.

Unannounced complaint investigation visit conducted due to multiple allegations including questionable death, inadequate assistance with bathing, residents left in soiled clothing, lack of clean clothing, and failure to assist with medication refills.

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 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.

The inspection visit was an unannounced complaint investigation triggered by allegations including unexplained bruising of a resident, residents not being provided pendants, and the facility lacking an administrator during hours of operation.

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 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 inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 09/25/2023 regarding staff response times, food availability, resident treatment, retaliation, nutrition, staffing levels, billing, and diet adherence.

The investigation found no preponderance of evidence to substantiate the allegations. Staff generally responded timely to call buttons, sufficient food was available, residents were treated with dignity, no retaliation was observed, nutritional needs were met, staffing was adequate, and residents were generally charged appropriately. The facility followed diet orders, although one resident declined the provided mechanical soft diet. No deficiencies were cited.

The complaint investigation was unsubstantiated. Allegations included untimely 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 with residents, staff, and document reviews did not support these allegations.

The inspection visit was an unannounced complaint investigation triggered by allegations that a resident sustained an unexplained medication overdose and became severely dehydrated while in care.

The investigation found that the resident was admitted to the hospital with lithium toxicity and acute kidney injury caused by poor food and fluid intake. Staff reported the resident refused to eat, drink, and take medications consistently. The facility's medication administration records were in order and medications were provided as ordered. The allegations were determined to be unsubstantiated due to lack of evidence that the facility caused the conditions.

The complaint involved two allegations: 1) Resident (R1) sustained an unexplained medication overdose, and 2) Resident (R1) became severely dehydrated while in care. The investigation included interviews with staff, family members, and the resident, as well as review of medical and facility records. The complaint was found unsubstantiated.

The visit was an unannounced case management inspection resulting from a complaint investigated by the Department regarding failure to seek immediate medical assistance for a resident.

The licensee failed to seek immediate medical assistance for resident R1, who was weak and refused to eat for several days before being sent to the hospital a week later. This posed an immediate risk to the health of the person in care.

The complaint involved failure to seek immediate medical assistance for resident R1 between 1/14/23 and 1/21/23, despite the resident's declining condition and family refusal to send the resident to the hospital. The licensee did not communicate with the resident's doctor on 1/14/23 and delayed hospital transfer until 1/21/23.

An unannounced complaint investigation was conducted regarding an allegation that the facility charged a resident for services that were not provided.

The allegation was found to be unsubstantiated after review of billing and service records and interviews with staff. The facility dropped all disputed charges, and the responsible party does not owe the facility.

The complaint alleged that the facility charged a resident for services not provided. The investigation found no preponderance of evidence to prove the violation, resulting in an unsubstantiated finding.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-01-24 regarding resident care issues at Pacifica Senior Living Union City.

The investigation substantiated that staff failed to notify a resident's authorized person of an injury, citing a violation of Title 22 California Code of Regulations. Other allegations including resident fracture, inadequate feeding, shower provision, room cleanliness, and call system accessibility were found unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated for the allegation that staff did not notify the resident's authorized person of injury. Other allegations including resident fracture, inadequate feeding, shower provision, room cleanliness, and call system accessibility were unsubstantiated. The investigation included interviews with staff and witnesses, and review of medical and facility records.

The visit was a case management inspection conducted due to a letter received from the facility regarding intent to delicense the third floor and convert units for independent individuals aged 55 and older without proper approval from Community Care Licensing.

The facility was found to have changed its plan of operation by advertising for independent renters aged 55 and older without obtaining approval from Community Care Licensing, posing a potential health, safety, or personal rights risk to assisted living residents. A deficiency was cited for this violation.

The visit was a case management visit conducted in connection with an incident reported by the facility involving an elopement of a resident.

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 visit was a case management visit related to a 30-day termination notice for resident R1 due to nonpayment of fees.

No deficiencies were noted during the visit. The facility is in the process of eviction for R1, who owes $7,321.67 and is awaiting a judge's decision.

The inspection was an unannounced complaint investigation conducted in response to a complaint received on 2023-06-13 alleging that staff were charging a resident for services not rendered.

The investigation substantiated the allegation that the facility charged resident R1 for a higher level of care than was assessed, constituting a potential personal rights violation. Another allegation regarding failure to provide a copy of the admissions agreement was unsubstantiated.

The complaint was substantiated based on evidence that resident R1 was charged for level three care after an assessment indicated level one care. The allegation regarding failure to provide a copy of the admissions agreement was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation of sexual abuse received on 07/26/2024.

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 complaint alleged sexual abuse. The resident interviewed did not recall the event and staff noted the resident's declining memory and possible hallucinations. The allegation was determined to be unsubstantiated.

The inspection visit occurred as a one annual inspection to evaluate compliance with regulations at the facility.

The inspection found that residents in the memory care unit were being locked inside their rooms during breakfast, which is a violation of residents' personal rights under California Code of Regulations, Title 22.

The visit was a case management inspection conducted in connection with an incident reported by the facility involving a resident elopement due to a gate that was supposed to be locked but was not.

The inspection found deficiencies related to failure to have an auditory device or staff alert feature to monitor exits, which led to a resident elopement when staff did not notice the resident had exited through an unlocked gate.

The visit was triggered by a complaint or incident report regarding a resident elopement caused by an unlocked gate that staff failed to monitor properly.

An unannounced annual 1-year required inspection was conducted to evaluate compliance with licensing regulations and facility safety standards.

The facility was generally compliant with safety and sanitation standards, including fire clearance, temperature control, and hygiene supplies. However, a deficiency was cited because 5 out of 5 staff members did not have current First Aid or CPR training on file.

An unannounced case management visit was conducted to serve an immediate exclusion order to staff member S1.

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

An unannounced annual 1-year required inspection was conducted to evaluate compliance with licensing regulations and facility safety standards.

The inspection found the facility generally compliant with safety and sanitation standards, including adequate lighting, temperature, and fire safety equipment. However, deficiencies were noted regarding unlocked cleaning supplies accessible to residents and inaccessible staff personnel files.

The inspection was an unannounced complaint investigation visit conducted due to allegations received on 2023-10-02 regarding mold presence and staff not providing a safe and comfortable environment at Pacifica Senior Living Union City.

The allegation that staff did not provide a safe and comfortable environment was found to be unsubstantiated based on observations and interviews with residents and staff. The allegation of mold presence was substantiated, with evidence of mold found in various resident apartments, posing a health and safety risk. The facility was cited for violation of CCR 87303(a) related to maintenance and operation.

The complaint investigation was triggered by allegations received on 2023-10-02. One allegation regarding mold presence was substantiated, while the allegation that staff did not provide a safe and comfortable environment was unsubstantiated.

The visit was a case management visit conducted in connection with an incident reported by the facility.

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 inspection was conducted unannounced on November 28, 2023, as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20231122143232).

The Licensing Program Analyst toured the facility and reviewed resident records, finding that the licensee failed to submit required Death and Unusual Incident Reports within seven days, posing potential personal rights risks to residents. Deficiencies were cited under Title 22 California Code of Regulations.

The visit was triggered by a priority 1 complaint (Complaint # 15-AS-20231122143232).

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-11-22 regarding the facility staff not ensuring that resident files were up to date.

The investigation found that 3 out of 4 residents reviewed did not have records in the emergency binder, confirming that the facility staff did not maintain complete and current resident records as required. The allegation was substantiated and a deficiency was cited.

The complaint was substantiated. It was alleged that facility staff did not ensure the resident file was up to date, specifically that the emergency binder contained blank pages and lacked accurate resident information for first responders.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff consumed alcohol while on duty at Pacifica Senior Living Union City.

The allegation that staff consumed alcohol while on duty was substantiated based on evidence obtained during the investigation. A deficiency was cited for failure to provide care and supervision meeting residents' needs due to staff alcohol consumption. The facility terminated the involved staff and planned in-service training.

The complaint was substantiated. The allegation was that staff consumed alcohol while on duty, resulting in inadequate care to residents. The investigation confirmed the incident occurred, and a deficiency was cited.

The inspection visit was an unannounced case management visit conducted during a complaint investigation (#15-AS-20230925101546).

Two deficiencies were observed: chemicals for floor repairs were stored in the kitchen area, and a tray of bacon was stored uncovered in the walk-in refrigerator along with other loosely covered containers. These deficiencies posed immediate and potential health and safety risks to persons in care.

The visit was conducted while investigating complaint #15-AS-20230925101546.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not safeguard a resident's personal belongings.

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 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 visit was a case management inspection conducted in connection with complaint 15-AS-20220526161218 regarding an elopement incident.

During the investigation, it was found that a resident with dementia wandered out of the facility on May 23, 2022, and the incident was not reported to the Community Care Licensing (CCL), resulting in a cited deficiency.

The visit was triggered by complaint 15-AS-20220526161218. The deficiency was substantiated as the facility failed to report the elopement incident to CCL.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-05-26 regarding staff not preventing a resident from wandering away and mismanaging resident's medication, as well as other allegations related to laundry needs and pests.

The investigation substantiated that a resident with dementia wandered away from the facility unassisted and that staff mismanaged the resident's medication by not administering it as prescribed. Other allegations regarding unmet laundry needs and pests in resident rooms were found to be unsubstantiated based on interviews and observations.

The complaint investigation was substantiated based on evidence that Resident 1 (R1) wandered away from the facility on 2022-05-23 despite having dementia and documented wandering behavior, and that medication administration records showed incomplete administration of Donepezil in May 2022. Other allegations about laundry needs and pests were unsubstantiated.

An unannounced Case Management visit was conducted to follow up on a substantiated complaint investigation regarding the facility's failure to seek timely medical attention for a resident, which resulted in amputation of the resident's right pinky toe.

The investigation confirmed that the facility staff failed to obtain timely medical attention for the resident, causing serious bodily injury requiring hospitalization and surgery. A civil penalty of $9,500 was issued for this serious bodily injury violation.

The complaint investigation was substantiated. The facility was cited for violating CCR Title 22, § 87465(a)(1) related to Incidental Medical and Dental Care. An immediate civil penalty of $500 was previously issued, and an additional civil penalty of $9,500 was assessed for serious bodily injury.

Unannounced complaint investigation visit conducted due to a complaint received on 2023-02-24 alleging that a resident developed an open sore while in care.

Investigation found that Resident 1 developed Stage 2 pressure injuries on the left posterior thigh and a Stage 1 pressure injury on the coccyx. The allegation was substantiated based on records review and interviews. A home health agency was contacted to provide wound treatment.

The complaint alleging that a resident developed an open sore while in care was substantiated based on the preponderance of evidence standard.

The inspection visit was an unannounced complaint investigation triggered by allegations received on 2023-02-24 regarding resident care issues including soiled clothing, unmet personal needs, and food temperature concerns.

Based on interviews with staff and residents, including the Memory Care Director, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Staff reported regular care practices such as timely changing of incontinent residents and ensuring clean clothing, and residents expressed satisfaction with care.

The complaint investigation was unsubstantiated. Allegations included residents being left in soiled clothing, unmet personal needs, and improper food temperature. Interviews with staff and residents did not support these claims.

The inspection was an unannounced complaint investigation visit triggered by allegations that residents' requests for assistance were not responded to in a timely manner, the facility did not have enough staff to meet residents' needs, and residents' rooms were not maintained at a comfortable temperature.

The investigation substantiated that staff failed to respond to call pendants in a timely manner, with at least nine calls responded to after 30 minutes or more, posing a potential risk to resident health and safety. However, allegations regarding insufficient staffing and uncomfortable room temperatures were unsubstantiated based on staff schedules, resident interviews, and observations.

The complaint investigation was substantiated for delayed response to residents' requests for assistance. Other allegations regarding staffing sufficiency and room temperature were unsubstantiated.

The inspection was conducted unannounced on February 13, 2023, as a result of the Department receiving a priority 1 complaint regarding the facility.

The inspection found that the hot water temperature was only 80 degrees Fahrenheit, which is below the required minimum, and that medications (Tylenol and Clobetasol cream) were unlocked in a resident's room despite the resident not being authorized to self-administer medications.

The visit was triggered by a priority 1 complaint (Complaint # 15-AS-20230209091605).

Unannounced complaint investigation visit conducted due to complaints received on 2021-08-26 regarding resident care issues including pressure injuries and medication administration.

The investigation substantiated that a resident sustained one Stage 2 pressure injury and one Stage 1 pressure injury, and that staff failed to administer prescribed medication (Donepezil) from 5/20/2021 to 6/22/2021. Other allegations such as weight loss, hygiene neglect, and inadequate feeding were unsubstantiated.

Complaint investigation was substantiated for allegations that resident sustained pressure injuries and medication was not administered as prescribed. Other allegations including weight loss, hygiene neglect, and inadequate feeding were unsubstantiated.

An unannounced case management visit was conducted to follow up on the criminal record exemption status of staff member S1.

The facility was found to have employed a non-cleared/excluded individual (S1) without criminal record clearance prior to employment, posing an immediate health and safety risk. S1 had been terminated on 08/29/22, and the deficiency was corrected during the visit with updated employment records.

An unannounced case management visit was conducted regarding self-reporting an AWOL incident involving a resident in the memory care unit.

The licensee failed to comply with safety measures for persons with dementia, as a resident was able to elope from the facility posing an immediate safety risk. The memory care unit's exit doors were observed locked during the visit. A deficiency was cited per Title 22 California Code of Regulations.

The visit was a case management and other type of inspection conducted to investigate concerns regarding Resident 2 not receiving assistance with brushing teeth.

The investigation found that Resident 2 is independent with activities of daily living and only requires cueing or reminders for some tasks such as brushing teeth. Staff provide the toothbrush but do not brush the resident's teeth. No deficiencies were noted during this visit.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-02-01 regarding staff failing to keep a resident's room clean and free of incontinence odors, failure to assist resident with showers, failure to maintain resident's equipment clean and sanitary, and facility disrepair.

The investigation substantiated the allegation that staff failed to keep a resident's room clean and free of incontinence odors, citing urine smell and stains on the carpet posing a potential health risk. Other allegations regarding failure to assist with showers, maintain resident's equipment clean, and facility disrepair were found to be unsubstantiated based on interviews and record reviews.

The complaint investigation was substantiated for the allegation that staff failed to keep a resident's room clean and free of incontinence odors. The other allegations related to failure to assist with showers, failure to maintain resident's equipment clean and sanitary, and facility disrepair were unsubstantiated.

An unannounced case management visit was conducted to deliver findings related to a complaint investigation.

Two deficiencies were identified: the facility did not have an updated medical assessment for resident R1, and the facility failed to submit a death report and report COVID-19 positive cases to the licensing agency as required.

The visit was complaint-related, and deficiencies were observed during the complaint investigation. The report does not explicitly state substantiation status.

An unannounced complaint investigation was conducted in response to an allegation that the facility did not provide a copy of the care plan to the authorized representative.

The investigation found that although the care plan was reviewed and signed, the facility did not provide a copy of the care plan to the resident or the resident's responsible party upon request, which was substantiated as a violation of regulations.

The complaint was substantiated based on the preponderance of evidence standard. The allegation was that the facility did not provide a copy of the care plan to the authorized representative, which was confirmed during the investigation.

The inspection was conducted as a case management visit in response to an incident report received on 2021-08-09 regarding a resident who left the facility unassisted.

The inspection found deficiencies related to the facility's failure to ensure the safety of residents with dementia, specifically a resident who left the facility unassisted, and issues with maintenance such as low audible delayed egress doors in the Memory Care Unit posing immediate health and safety risks.

The visit was triggered by an incident report dated 2021-08-09 about a resident who left the facility unassisted (AWOL). The resident was found by police and taken to Kaiser Hospital. The physician's report dated 2021-04-01 stated the resident cannot leave unassisted. The complaint was substantiated by observed deficiencies.

An unannounced Infection Control Inspection was conducted as a required 1-year visit to assess infection control practices at the facility.

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.

Licensing Program Analyst Luisa Fontanilla conducted case management in connection with an SOC 341 received by the agency. The purpose of the call was explained to the Executive Director.

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.

Unannounced complaint investigation visit conducted due to allegations that staff did not respond to resident's call button in a timely manner, did not assist resident with toileting needs timely, and did not feed resident in a timely manner.

The investigation substantiated that staff did not respond to call buttons or assist with toileting needs in a timely manner, posing potential health and safety risks. The allegation regarding untimely feeding was found unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for allegations that staff did not respond timely to call buttons and did not assist with toileting needs timely. The allegation that staff did not feed resident timely was unsubstantiated.