306001848-7-1-2025-22-AS-APAO-DJG9NQ-20250710233132

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001848
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:13:38 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
08/23/2021 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20210823130330

FACILITY NAME:	PACIFICA ROYALE ASSISTED LIVING COMMUNITY		FACILITY NUMBER:	306001848
ADMINISTRATOR:	EDWARD MASLOBODSKY		FACILITY TYPE:	740
ADDRESS:	15022 PACIFIC ST.		TELEPHONE:	(714) 892-4446
CITY:	MIDWAY CITY	STATE: CA	ZIP CODE:	92655
CAPACITY:	132	CENSUS: 77	DATE:	07/01/2025
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Edward Maslobodsky		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff did not meet resident's dental hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to continue an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on August 23, 2021 by LPA Lydia Martinez. During the visit, LPA Martinez obtained documents related to the complaint and interviewed staff.

It was alleged faciity staff did not meet resident's dental hygiene needs. During the investigation, LPA Arias conducted interviews with residents in care and staff. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation facility staff did not meet resident's dental hygiene needs, it was reported during an emergency admission at a hospital in 2021, resident 1 (R1)'s dentures were found to be dirty and black with old corroded denture adhesive.

Continued on LIC9099-C dated 07/01/2025

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (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)

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Control Number 22-AS-20210823130330

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 four residents stated they had no issues with assistance with getting dental or medical appointments if needed. One out four residents interviewed wears dentures and stated they clean their own dentures but will notify the staff if cleaning supplies are needed. LPA interviews with two out of two staff stated the facility arranges medical and dental appointments along with transportation to those appointments. Two out of two staff stated R1 was cognitive and was able to make their own decisions. In addition, two out of two staff stated R1 was able to eat and brush their teeth on their own. One out of two staff also added they were a primary caregiver for R1 and R1's dentures were observed to be in good condition while R1 lived at the facility. LPA reviewed R1's records available.

Therefore based on client interviews, staff interviews, records reviewed, and LPA observations, the allegation of facility staff did not meet resident's dental hygiene needs is 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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (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)

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