<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001848
Report Date: 01/23/2024
Date Signed: 01/23/2024 12:09:27 PM

Unsubstantiated


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
01/19/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240119113253
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: 65DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Edward MaslobodskyTIME COMPLETED:
12:38 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff threatened a resident after the resident refused to take a prescribed medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Edward Maslobodsky arrived during the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and resident as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that facility staff threatened a resident after the resident refused to take a prescribed medication, the investigation revealed the following: Resident 1 (R1) is prescribed Risperidone 1 MG by mouth twice daily for Schizophrenia. Resident has started refusing that medication along with other prescribed medication. Resident states refusing medication as it was prescribed by a primary care physician and not the resident's psychiatrist as well as side effects from the medication. Facility arranged for physician to see the resident on 01/19/2024 regarding medication changes and refusals. Physician notes indicate the resident's desire to discontinue the medication along with physician concern over discontinuing the medication and the resident's current psychiatric state. CONTINUED ON LIC 9099C DATED 01/23/2024
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20240119113253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PACIFICA ROYALE ASSISTED LIVING COMMUNITY
FACILITY NUMBER: 306001848
VISIT DATE: 01/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Two out of two staff deny the resident was threatened in any way or coerced into taking medication. Facility staff indicate assisting resident with the process to discontinue medications. Based on interviews conducted and record review, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2