Non-compliance follow-up·August 28, 2025

At approximately 8:55 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-one (21) residents in Assisted Living (AL) and twenty (20) residents in Memory Care (MC) for a total of forty-one (41) 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 facility reported that AL is not in accord in regards to staffing per the stipulation. As this is being investigated as part of complaint 21-AS-20250808144348 it will not be cited today. The facility has hired additional staff since LPA's last Non-Compliance inspection on 7/24/2025. 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 facility call system logs for from 8/19/2025 through 8/27/2025. LPA observed thirteen (13) instances where the call system response times exceeded fifteen (15) minutes. The longest response time being one (1) hour, one (1) minute and fifty-six (56) seconds. 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. LPA reviewed stipulation training documents for four (4) staff members. During audit of stipulation training documents, LPA observed that staff had completed the stipulation training as required. During Today's inspection, LPA toured the AL, MC 1 and MC 2 buildings. LPA also toured the facility grounds. No deficiencies cited during today's visit. Exit interview conducted. Copy of report and discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.