18 MONTEREY COUNTY WEEKLY FEBRUARY 6-12, 2025 www.montereycountynow.com Pick was one of the lawyers representing the family of Phyllis Johnson, who sued Pacifica Senior Living for elder neglect and wrongful death after Johnson died in 2021. The active 88-year-old woman fell and broke two bones in her lower leg. She had surgery to repair the leg and was transferred to a temporary rehabilitation center, followed by transfer to Healdsburg Senior Living Community, owned by Pacifica, for skilled nursing. Skilled nursing was not an area the company was familiar with. The Healdsburg facility was part of a package deal that included other senior facilities like assisted living and memory care, which had been the focus since it was first founded. At the time, Pacifica only operated two other nursing facilities, says Sanford Horowitz, who also represented the family. “They were stuck with operating a [skilled nursing facility], so it was the hated step-child,” Horowitz says. Skilled nursing requires a higher level of staffing, yet Healdsburg was treated like other facilities Pacifica has purchased—staffing and services were cut soon after the company took over. Three weeks after Johnson was admitted to Healdsburg Senior Living Community, she was dead. She had been rushed back to the hospital where she died of septic shock, stemming from a pressure ulcer near the base of her spine. In a draft report prepared by consultant Christopher Cherney for Johnson’s family, Cherney outlined what he called “a complete breakdown in HSLC systems of care provision,” blaming “violations of professional standards, as well as federal nursing home requirements.” He found nursing staffing levels to be 43-percent below state minimums on average during Johnson’s stay, including not hiring a director of nursing, as required by the state. Johnson’s death was directly attributed to the failures of Pacifica Senior Living and its executives, including Israni, Cherney said. His report was never heard in court. Pacifica settled the case last year for $2.5 million. The family returned to court recently over the company’s failure to pay in a timely manner. Since Johnson’s death, HSLC has been stripped of its state license, a rare step according to senior advocates, claiming that officials with the State Department of Social Services avoid taking away licenses, which would send families scrambling to find other locations that may not have enough beds or exist nearby. In general, advocates are highly critical of state oversight, or the lack thereof. Patricia McGinnis, an adviser to the nonprofit California Advocates for Nursing Home Reform (CANHR) who’s worked for the organization for decades, is critical of what she calls “substandard care” provided by most facilities in the state and the “shoddy work” done by state evaluators. She says they often do “brush-by” investigations when complaints are lodged, resulting in many labeled as unsubstantiated, possibly a byproduct of a system that’s been underfunded historically by legislators. The California Department of Social Services manages over 72,000 licenses for a variety of facilities, according to McGinnis, including those for the elderly, like residential care facilities, continuing care retirement communities and memory care (see sidebar, p. 20). Many complaints filed by facilities are marked as unsubstantiated. Complaints that are substantiated come with required corrections, but McGinnis contends there is usually not enough follow-up. Many years ago, the complaints CANHR received were about food, as well as theft and loss. In recent years the complaints are more serious, like residents not receiving medication, or medication mix-ups. “Nobody seems to care,” McGinnis says. “That’s the problem.” PGSL has a license in California for both what’s known as a residential care facility for the elderly and a continuing care retirement community, and as such is under the purview of the Department of Social Services (DSS). Since Pacifica took over in 2022, DSS evaluators have visited the site 20 times to investigate 40 complaints. Of those, 23 were considered unsubstantiated, 10 unfounded, and seven substantiated. Pacifica was cited last October and July for not having hot water for residents, and received two citations in the case of the attempted eviction of 96-year-old Jean Jacques in August because management claimed she owed them $109,000 in back rent and fees. Jacques had a continuing care contract with the previous owners that guaranteed her care for the rest of her life even after she ran out of money, which Pacifica was ordered to abide by as a condition of the sale out of bankruptcy. After Jacques’ story went viral, Pacifica executives reversed their decision. The company was also cited last fall for making a substantial change to its operations without prior approval, since it started advertising housing for independent living, apart from its approved plan for assisted living. Managers told the DSS evaluator they would talk to upper management about making a formal request to make the change. By contrast, Canterbury Woods, located just a block away from PGSL and run by nonprofit Front Porch, had one substantiated complaint in 2023 for not providing enough hydration to an assisted living resident. Carmel Valley Manor has zero complaints on its recent DSS record. In addition to PGSL, Pacifica also owns The Park Lane in Monterey, which has an assisted living license. Since 2020 that facility has been visited 19 times with nine citations issued. In all, 33 allegations were unsubstantiated, five unfounded and five substantiated. The citations included not seeking timely medical attention for a resident who fell, failing to refund money to a responsible party after a resident’s death and failure to administer medication. Residents upset with Pacifica’s management have contacted other agencies for help. Last year, their persistence resulted in the City of Monterey investigating a roof leak that had been ongoing for about four years. The city issued a code violation to Pacifica for failing to repair the leak. At least two apartments had mold issues, resulting in one resident having to move out before the city’s visit. City officials tagged that apartment as unsafe in May. When Pacifica took too long to make repairs, the city threatened fines. The roof has since been repaired, according to a city building official. A kitchen fire at The Park Lane last summer resulted in the discovery that the fire alarm system wasn’t working, possibly due to rodents chewing on wires. The Monterey Fire Department required Park Lane employees to patrol the building on fire watch until the system could be repaired. Rats are suspects because they have been spotted by residents, and signs of their activity were seen on a regular basis last summer and fall in the dining area. The Monterey County Health Department has been monitoring the situation, which has improved, but they have not closed the case. At one point last summer the kitchen was shut down by the health department for three days. Instead of the quality meals residents were once promised at what is advertised as “luxury senior living,” they were served pizza on paper plates. County health inspectors have been out multiple times and Pacifica management has promised to follow up with rodent control. At a resident town hall meeting in August, the company’s Regional Director Aaron Windbigler detailed how they had a contractor coming out to inspect twice a week, as well as trimming trees away from buildings to deter roof rats. Residents say the work to control rats is ongoing. Top: President and CEO Jay Zimmer at Carmel Valley Manor, which has apartments up to regular homes, plus an assisted living center and a skilled nursing facility. Below: Carmel Valley Manor resident Robin Sawyer works out with the help of trainer Matt Burke in the gym. There’s also a pool, lawn bowling and multiple indoor activity rooms, including a library, art room, sewing room and even a room with looms for weaving.
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