Inspection Reports for
Pacifica Senior Living Union City

The facility was found to have several deficiencies including unlocked topical cream posing immediate safety risk, improperly stored and labeled food, and lack of updated physician's reports for residents. The facility was cited under California Code of Regulations and Health and Safety Code with plans of correction required.

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.

The complaint investigation was triggered by Complaint Control # 15-AS-20230209091605. The complaint was substantiated based on the findings that the facility did not seek timely medical care for resident R1 despite the resident's deteriorating condition.

The facility 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 noncompliance posed an immediate health risk to the resident.

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.

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 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 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 were unsubstantiated. The investigation included interviews, record reviews, and medical documentation. The deficiency cited was per Title 22 California Code of Regulations section 87211(a)(1).

The investigation found one substantiated deficiency related to failure to notify the resident's authorized person of injury, posing a potential health and safety risk. Other allegations including resident fracture, inadequate feeding, shower provision, room cleanliness, and call system accessibility were unsubstantiated.

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 and safety risk. A deficiency was cited for this violation.

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 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.

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 investigation was triggered by allegations that staff charged a resident for services not rendered and failed to provide a resident with a copy of the admissions agreement. The allegation regarding overcharging was substantiated, while the admissions agreement allegation was unsubstantiated.

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

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

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. Deficiencies were cited from the California Code of Regulations, Title 22.

The inspection found that residents in the memory care unit were being locked inside their rooms, which violates the residents' personal rights under California Code of Regulations, Title 22. The licensee did not comply with the regulation prohibiting locking residents inside their rooms at any time.

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

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 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.

The inspection found the facility generally maintained safe and sanitary conditions, including adequate lighting, temperature, and fire safety equipment. However, deficiencies were noted related to unlocked disinfectants and cleaning solutions accessible to residents and inaccessible staff personnel files.

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 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 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 substantiated for the allegation of mold presence and unsubstantiated for the allegation that staff did not provide a safe and comfortable environment.

The allegation that staff did not provide a safe and comfortable environment was unsubstantiated based on observations and interviews with residents and staff. The allegation of mold presence was substantiated, with evidence of mold found in residents' apartments and AC units, posing a potential health and safety risk.

The complaint was substantiated. It alleged that facility staff did not ensure the resident file was up to date, specifically that emergency binders contained blank pages preventing staff from providing accurate information to first responders.

The investigation found that 3 out of 4 residents reviewed did not have records in the emergency binder, confirming that the resident files were not up to date. The allegation was substantiated and a deficiency was cited under Title 22 CCR 87506(a).

The visit was triggered by a priority 1 complaint (Complaint # 15-AS-20231122143232). The complaint was substantiated by findings of failure to submit required reports within seven days, posing potential personal rights risks to residents.

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

The visit was triggered by 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 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 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 alleged staff consumed alcohol while on duty. The allegation was substantiated with evidence of staff drinking beer on facility premises during work hours. The Executive Director confirmed the incident and terminated the involved staff. A second allegation that residents were neglected due to staff alcohol consumption was unsubstantiated.

The allegation that staff consumed alcohol while on duty was substantiated based on the preponderance of evidence. The facility cited a deficiency for failure to provide care by staff who consumed alcohol, posing potential safety and personal rights risks to residents. The Executive Director terminated the involved staff and planned in-service training. Another allegation that residents were not provided adequate care due to staff alcohol consumption was unsubstantiated.

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 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 visit was conducted as part of complaint investigation #15-AS-20230925101546.

Two deficiencies were observed: chemicals for floor repairs were stored in the kitchen area posing an immediate health and safety risk, and perishable foods were stored without proper covering, posing a potential health and safety risk. Staff removed the chemicals during inspection and discarded uncovered bacon.

The visit was conducted while investigating complaint #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 triggered by complaint 15-AS-20220526161218. The deficiency related to failure to report the elopement incident was substantiated.

The facility failed to report an elopement incident that occurred on May 23, 2022, when a resident with dementia wandered out of the Memory Care Unit, which poses a potential threat to the safety of clients in care.

The complaint investigation was substantiated based on evidence that a resident wandered away from the facility on 5/23/2022 and that medication administration records showed incomplete medication administration for the resident. The allegations about laundry needs and pests were unsubstantiated.

The investigation substantiated that a resident with dementia wandered away from the facility unassisted and that the resident's medication was not administered as prescribed. Two other allegations regarding unmet laundry needs and pests in residents' rooms were found to be unsubstantiated.

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

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 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.

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. The facility did not seek timely medical attention for resident R1, resulting in amputation of the right pinky toe. An immediate civil penalty of $500 was previously issued, and an additional civil penalty of $9,500 was assessed for serious bodily injury.

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

The complaint was substantiated. Resident 1 developed pressure injuries while in care. The investigation included interviews and record reviews. A home health agency was contacted to provide wound treatment. The licensee did not comply with California Code of Regulations Title 22.

The 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 staff interviews. The facility did not comply with the requirement to provide care, supervision, and services that meet individual needs.

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.

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

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 investigation was substantiated for the allegation that residents' requests for assistance were not responded to in a timely manner. The allegations that the facility did not have enough staff to meet residents' needs and that residents' rooms were not maintained at a comfortable temperature were unsubstantiated.

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

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 complaint investigation was substantiated for allegations of pressure injuries and medication administration failure. Other allegations including weight loss, hygiene neglect, and inadequate feeding were unsubstantiated.

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 5/30/2021 to 6/22/2021. Other allegations related to weight loss, hygiene, and feeding were unsubstantiated due to insufficient evidence.

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.

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.

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. An immediate civil penalty of $500 was assessed. The deficiency was corrected during the visit with termination documentation and updated employment records.

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.

The licensee failed to comply with safety measures to prevent wandering of a resident with dementia, resulting in the resident eloping and posing an immediate safety risk. A deficiency was cited related to care of persons with dementia.

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

The investigation substantiated the allegation that staff failed to keep a resident's room clean and free of incontinence odors, citing a violation of California Code of Regulations Section 87625(b)(3). Other allegations regarding failure to assist with showers, maintain equipment cleanliness, and facility disrepair were found to be unsubstantiated.

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.

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

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 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. The investigation included interviews, record reviews, and email correspondence confirming the responsible party's request for the care plan copy.

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, substantiating the allegation.

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

The facility was found deficient for not having an updated medical assessment on file for resident R1 and for failing to submit a death report for a resident who expired and tested positive for COVID-19, as well as not reporting positive COVID-19 cases to the licensing agency as required.

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 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 visit was triggered by a complaint incident report dated 2021-08-09 about a resident who left the facility unassisted and was found by police and taken to the hospital. The complaint was substantiated by the findings.

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 the delayed egress alarm system 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.

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 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.

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.