Pacifica Senior Living Union City

Based on observation and record review, the licensee did not comply with the section cited above by having unlocked prescription of topical cream in R1's room which poses an immediate safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not properly storing and labeling food which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having updated medical assessment for residents in care which poses a potential health and safety risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility......... (2) The licensee shall provide assistance in meeting necessary medical and dental needs……...-This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section in not seeking immediate medical assistance for resident (R1) which posed an immediate risk to the health risk to person in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence... evidence by: This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above by notifying the responsible party, which poses a potential health and safety risk to persons in care.

“…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval."This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety or personal rights risk to persons in care.

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R1 for services not rendered which poses a potential personal rights violation to the persons in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.-This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for locking residents inside their room in memory care unit.

87705 Care of Persons with Dementia(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by:S1 stated that the gate that was supposed to be lock was not lock that led to an elopement. During the time resident was led outside by Activity assistance for an activity. The staff didn’t notice that the resident had went outside the gate.

Based on interview and record review, the licensee did not comply with the section cited above by 5 out of 5 staff did not have first aid or CRP on files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having files for the staff avaliable for review which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having unlocked disinfectants and cleaning solutions accessible which poses an immediate health and safety or personal rights risk to persons in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by: Based on interviews and documentation review the facility has/had mold in various resident apartments which poses/posed an immediate/potential Health, Safety or Personal Rights risk to persons in care

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured -This requirement is not met evidenced by:-Based on record review, the licensee did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by:-Based on records review and interviews, the licensee did not comply with the section above for not having records in the emergency binder for 3 out of 4 residents which pose potential health and personal rights risks to persons in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events.....(D) Any incident which threatens the welfare, safety or ........ ......health of any resident......-This requirement is not met evidenced by:-Based on record review, the licensee did not comply with the section above for not submitting an incident report within 7 days which posed potential personal rights risk to person in care.

87468.2 Additional Personal Rights ....(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities.... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... ....to meet their needs.-This requirement is not met as evidenced by:-Based on interviews, the licensee did not comply with the section above when staff consumed alcohol while in the facility which posed a potential safety and/or personal rights risks to persons in care.

General Food Service Requirements. All readily perishable foods... shall be stored in covered containers... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing foods without covered container which poses a potential health and safety risk to the persons in care.

General Food Service Requirements. Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing chemicals in the kitchen area which poses an immediate health and safety risk to the persons in care.

(a) Residents of residential care facilities for the elderly shall have all of the following rights:(10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by:This requirement is not met as evidenced by: On May 23, 2022, R1 wandered out of the building. R1 has dementia and medical records indicate R1 is not allowed to leave the facility unassisted.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such report...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:R1 who has dementia and is not allowed to leave facility unassisted wandered out of the facility on 5/23/2022 but facility failed to report incident to CCL which poses a potential threat to safety of clients in care.

87465(a)(4) Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed....(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:Based on review of MAR for May 2022, R1 was given Donepezil for only 9 days.

§1569.269 Enumerated rights:(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered...This requirement is not met as evidenced by: Based on records review and interviews conducted, the licensee did not comply with the section above when R1 developed Stage 2 pressure injuries on left posterior thigh and Stage 1 pressure injury on coccyx which posed an immediate health

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...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient…This requirement is not met as evidenced by: Based on records reviewed, facility staff failed to respond to pendants in timely manner, based on records review, at least nine calls from R1 & R2 that staff responded within 30 minutes or more, which poses a potential risk to the health and safety of resident under care.

87303 Maintenance and Operation(e)(2) 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:-Based on observation, the licensee did not comply with the section above for water temperature tested and measured at 80 degrees Fahrenheit which poses ummediate safety & personal right risks to persons in care.

87465 Incidental Medical and Dental Care (h):(1) Medications shall be centrally stored ....:(B)Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed -This requirement is not met as evidenced by:-Based on inspection, the licensee did not comply with the section above for R1's medications unlocked which pose immediate health risk to person in care.

87465(a)(5) Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility.....(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications…. This requirement is not met as evidenced by: Based on records review, the Licensee did not comply with the regulations cited above when R1 was not given Donepezil from 5/30/2021 to 6/22/2021 which poses an immediate health and safety risk residents in care.

§1569.269(a)(10) Enumerated rights; severability(10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on records review, Licensee did not comply with the regulation cited above. R1 sustained one Stage 2 coccyx pressure ulcer and one Stage 1 pressure injury on right hip which poses an immediate health and safety risk to residents in care.

The Department shall conduct a criminal record review of all individuals ...any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by staff (S1) not having criminal record clearance prior to employment which posed an immediate health & safety risk to residents in care.

87705 Care of Persons with Dementia(b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.-This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above for retaining R1 with dementia. R1 was able to AWOL which posed immediate safety risk to person in care.

(b) In addition to Section 87611, General Requirements for Allowable... the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that ...incontinence.This requirement is not met as evidenced by: Based on investigation:During the televisit conducted by LPA on 2/5/2021, former RSD confirmed with LPA that there was urine smell and stains on the carpet in R1’s room which poses a potential risk to health and safety of client

Additional Personal Rights of Residents in Privately Operated Facilities. To have prompt access to review all of their records and...Photocopied records shall be provided within two (2) business days... This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing a copy of care plan to R1's responsible party which poses a potential health and safety risk to the persons in care.

Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not reporting COVID positive cases and submit death reports which poses a potential health and safety risk to the persons in care.

Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...at least annually... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having an updated medical assessment for R1 which poses a potential health and safety risk to the persons in care.

Care of Persons with Dementia. Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement is not met as evidence by:Based on record review, licensee did not comply with the section cited above due to resident AWOL which poses a potential health and safety risk to the residents in care.

Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times....This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by having a low audible delayed egress doors in Memory Care Unit which poses an immediate health and safety risk to the residents in care.