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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004640
Report Date: 03/10/2025
Date Signed: 03/10/2025 02:51:40 PM

Substantiated


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
06/17/2021 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210617131615
FACILITY NAME:PACIFICA SENIOR LIVING NEWPORT MESAFACILITY NUMBER:
306004640
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2891 BEAR STTELEPHONE:
(949) 629-1020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:40CENSUS: 22DATE:
03/10/2025
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Rose NakadairaTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Medication was not administered to residents appropriately
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Rose Nakadaira and explained the reason for today’s inspection.

The investigation into the allegation that medication was not administered to residents appropriately revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s Medication Administration Records.

CONTINUED
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
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 5
Control Number 22-AS-20210617131615
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 SENIOR LIVING NEWPORT MESA
FACILITY NUMBER: 306004640
VISIT DATE: 03/10/2025
NARRATIVE
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It was alleged that a resident was prescribed a medication to be taken every day for 21 days, but was only given the medication for three days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating the allegation. LPA inspected the medications for these 10 residents and noted no medication errors. However, LPA reviewed the Medication Administration Records for these 10 residents and noted that all 10 residents have missed doses of medications in the last three months due to the medications not being in stock at the facility, including medications for blood pressure and heart conditions. Per AD, reasons for these medications not being in stock at the facility include residents’ families not bringing in the medications and doctors not timely providing refill prescriptions before the medications ran out. The information obtained corroborated the allegation.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20210617131615
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 SENIOR LIVING NEWPORT MESA
FACILITY NUMBER: 306004640
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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The licensee stated they will submit a plan to ensure residents medications are refilled timely to LPA by POC due date.
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Based on documents and interviews, the licensee did not ensure 10 out of 10 residents received assistance with medications when the facility ran out of supply, which poses an immediate health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/17/2021 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210617131615

FACILITY NAME:PACIFICA SENIOR LIVING NEWPORT MESAFACILITY NUMBER:
306004640
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2891 BEAR STTELEPHONE:
(949) 629-1020
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:40CENSUS: 22DATE:
03/10/2025
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Rose NakadairaTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Resident's care needs are not being met
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Rose Nakadaira and explained the reason for today’s inspection.

The investigation into the allegation that resident's care needs are not being met revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and recent wound care records.

CONTINUED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20210617131615
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 SENIOR LIVING NEWPORT MESA
FACILITY NUMBER: 306004640
VISIT DATE: 03/10/2025
NARRATIVE
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It was alleged that a resident sustained an injury at the facility, received stitches and needed their bandages changed daily, but the bandages were not changed for over three or four days. LPA inspected the facility, conducted health and safety checks on all residents present, and did not observe any health and safety issues. LPA interviewed AD who denied the allegation. LPA interviewed three staff and did not obtain information corroborating the allegation. LPA interviewed 10 residents and did not obtain information corroborating any unsafe conditions, lack of medical treatment, or issues regarding care and supervision. LPA reviewed recent wound care records which showed that the most recent wound at the facility was properly treated and had healed. Interviews with AD and staff revealed that the facility is properly identifying residents with wounds, ensuring they receive proper wound care, and ensuring wound care is properly documented. The information obtained did not corroborate the allegation.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5