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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306001848
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:12:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/05/2024 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20240305134345
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: 77DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Edward MaslobodskyTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff bathed a resident with cold water causing the resident pain.
Staff made inappropriate comments to a resident.
Staff did not treat a resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to continue an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on March 14, 2024 by LPA Celine Rodriguez. During the visit, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged staff bathed a resident with cold water causing the resident pain, staff made inappropriate comments to a resident and staff did not treat a resident with dignity and respect. During the investigation, LPA Arias conducted interviews with residents in care and staff. LPA Arias reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff bathed a resident with cold water causing the resident pain, it was reported staff used cold water while bathing resident that caused pain in their legs.
Continued on LIC9099-C dated 07/01/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred AriasTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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-20240305134345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PACIFICA ROYALE ASSISTED LIVING COMMUNITY
FACILITY NUMBER: 306001848
VISIT DATE: 07/01/2025
NARRATIVE
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LPA interviews with four out of five residents stated they had no issues with assistance with showers from staff. Four out of five residents stated staff always wait until the water is warm enough before placing resident in the shower. One out of five residents stated they were once placed in the shower first and then the water was turned on with the shower head pointing to the side, causing cold water to splash from against the wall onto their body causing pain. LPA interviews with three out of three staff stated it is standard to turn on the water and adjust the temperature before placing the resident in the shower but sometimes the procedure varies based on the preference and needs of the resident. Three out of three staff stated showers are never given with cold water. One out of three staff stated water temperatures can vary at times depending on water usage in nearby bathrooms.

Regarding the allegation staff made inappropriate comments to a resident, it was reported staff called a resident a "baby" and was told "don't be a baby" during a shower. LPA interviews with four out of five residents stated staff have never made inappropriate comments towards them. One out of four residents stated they were told "don't be a baby" during a shower. LPA interviews with three out of three staff stated they have never made inappropriate comments to residents. One out of three staff added any complaints about inappropriate comments would be addressed immediately.

Regarding the allegation staff did not treat a resident with dignity and respect, it was reported a staff member is dismissive and exhibits gossiping behaviors about a resident. LPA interviews with five out of five residents stated they are unaware of any dismissive or gossiping behaviors by staff. LPA interviews with three out of three staff denied any dismissive or gossiping behaviors.

LPA record review for two staff present revealed they have received mandatory reporting requirements training.

Therefore based on client interviews, staff interviews, records observed, and LPA observations, the allegations of staff bathed a resident with cold water causing the resident pain, staff made inappropriate comments to a resident, and staff did not treat a resident with dignity and respect are therefore deemed unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of the report was left with the facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred AriasTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2