Non-compliance follow-up·September 25, 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), eight (8) residents in Memory Care Unit 1 (MC1) and thirteen (13) residents in Memory Care Unit 2 (MC2) for a total of forty-two (42) 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. 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 Respondent Pacifica understands that facility staff must be hired in numbers necessary to meet the needs of the residents. To that extent, each 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 During inspection LPA reviewed staff schedules from 8/29/2025 through the day shift of 9/25/2025. LPA was informed that the day shift is from 6:00AM to 2:00PM and that the Evening shift is from 2:00PM to 10:00PM. During review of staff schedules LPA observed the following: 8/29/2025: MC2 had only one (1) Caregiver (CG) during the evening shift. 8/30/2025: MC2 had only one (1) CG during the day shift. 9/1/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) per day and evening shifts. 9/2/2025: MC2 had only one (1) CG per the day and evening shifts. 9/3/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the day shift. MC2 had only one (1) CG for the evening shift. 9/4/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift . 9/5/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/6/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/7/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/8/2025: MC2 had only one (1) CG during the day shift. AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/10/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/11/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) per day and evening shifts. 9/12/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/13/2025: MC2 had only one (1) CG during the day shift. 9/14/2025: MC2 had only one (1) CG during the day shift. 9/15/2025: AL, MC1 and MC2 shared only one (1) Medication Technician (MT) for the evening shift. 9/18/2025: MC2 had only one (1) CG during the day shift. 9/19/2025: MC2 had only one (1) CG during the day shift. 9/25/2025: MC2 had only one (1) CG during the day shift. Continued on 809-C2... ...Continued from 809-C As the facility did not provide adequate staff to meet the needs of residents in care a citation will be issued. The facility was cited for the same deficiency on 10/16/2024,11/19/2024, 5/6/2025 and 7/24/2025. As this repeat deficiency occurred within one (1) year of the previous citations, a Civil Penalty of $1000.00 will be assessed. The facility is constructing an additional building for residents directly behind the primary AL building. The building under construction is next to garden area. While conducting the inspection of the facility grounds LPA observed that the temporary fencing intended to block off the area under construction was knocked down and moved allowing access to the construction area. LPA further observed the door to the new building was propped open. LPA entered the building under construction and observed trip hazards and unsecured toxins. LPA observed that there was no staff or construction personnel in the area. The construction area contained trip hazards and unsecured toxins that could be dangerous to the facility's residents in care. The facility will be issued a citation for not ensuring the construction area was properly secured. LPA has video showing access to the construction area showing the trip hazards and unsecured toxins. 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-809Ds, LIC-421IM, Plan of Corrections and Appeal Rights discussed and provided to ED Rodriguez. Signature on form confirms receipt of documents.