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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001848
Report Date: 08/26/2020
Date Signed: 08/27/2020 11:20:15 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2020 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200817113429
FACILITY NAME:PACIFICA ROYALE ASSISTED LIVING COMMUNITYFACILITY NUMBER:
306001848
ADMINISTRATOR:EDWARD MASLOBODSKYFACILITY TYPE:
740
ADDRESS:15022 PACIFIC ST.TELEPHONE:
(714) 892-4446
CITY:MIDWAY CITYSTATE: CAZIP CODE:
92655
CAPACITY:132CENSUS: 98DATE:
08/26/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Edward MaslobodskyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff unlawfully evicted resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lydia Martinez contacted the facility via telephone to initiate and deliver findings on a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Administrator Edward Maslobodsky. LPA conducted three (3) staff interviews, and one (1) witness interview regarding the allegation. It was alleged that staff unlawfully evicted Resident 1 (R1) while in care. Interview with Administrator stated R1 was not evicted and R1 continues to live at the facility. Administrator and staff stated facility received a call from the Hospital reporting that R1 was hospitalized and asked if R1 was a resident at the facility to which staff responded that R1 was a resident. Staff told hospital staff that R1 goes for walks alone and returns daily. Residents come and go as they please as "this is not a locked facility" and that is why R1 was out in the community. Allegation is deemed Unfounded, meaning the allegation is false could not have happened and/or is without a reasonable basis. An exit interview was conducted with Administrator Maslobodsky via phone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Administrator to sign and return copy to LPA.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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