Non-compliance follow-up·July 24, 2025

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Legal Non-Compliance Case Management inspection and met with Executive Director (ED) Brandee Rodriguez. LPA was informed that there are twenty-two (22) residents in Assisted Living and seventeen (17) residents in Memory Care for a total of thirty-nine (39) residents. As a requirement of the Stipulation and Waiver; and Order dated, 6/30/2022, the facility submitted a Monthly Quality Assurance (QA) Audit that includes but is not limited to staffing, physical plant, dementia care, medication records and infection control. LPA reviewed QA and which noted that the Ice machine, storage shelving for frying pans and top of pan steamer needed to be cleaned. LPA inspected items noted and observed them to have been cleaned. The following items are some of the requirements required per the current Stipulation and Waiver and Order (dated 6/30/2022) in place for the facility: Facility shall provide a minimum of four (4) hours of training monthly to direct care staff and managers. All staff that provide medication administration must receive one additional hour of training every month. Pacifica shall perform quarterly audits of medication inventory and if errors are found, a plan of correction for each error found shall be included with the applicable audit report Memory Care Unit and Assisted Living unit shall be staffed independently, such that the units do not share direct care staff. The Med Tech will not be a direct care staff, but may provide support when not distributing medication. Facility call system and delayed egress shall at all times be fully functional. Continued on 809-C... ...Continued from 809 LPA reviewed the most recent staff schedule to verify that facility has sufficient staff for resident's needs including but not limited to residents needing two person assists. Facility was observed to have inadequate staffing in Memory Care 2 (MC2) and Assisted Living (AL). This deficiency is being cited on complaint number 21-AS-20250625095039. Facility provides monthly training to staff in order to comply with the Stipulation and Waiver, and Order and contracts with a vendor to ensure the staff training requirement are met. During audit of stipulation training documents LPA observed that staff member (S1) did not complete the required medication administration training for May 2025 and for June 2025. This deficiency will be cited. As this deficiency was previously cited within the past year (1/29/2025) a Civil Penalty of $250.00 will be assessed. LPA spot checked Medication for four (4) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, LIC-421FC, LIC-811 Confidential Names and Appeal Rights discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.