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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004640
Report Date: 10/26/2023
Date Signed: 10/26/2023 10:39:15 AM

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
12/09/2020 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20201209154307
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: 24DATE:
10/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosie NakadairaTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Facility planned group activities without the use of proper PPE
Facility failed to cohort covid positive residents from covid negative residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director Rosie Nakadaira and explained the reason for the visit. The investigation into the allegation, facility planned group activities without the use of proper PPE revealed the following. It was alleged that staff did not use PPE properly during a staff led resident outing and this led to many staff and residents testing positive for Covid-19. Staff interviewed reported that the outing on 11/21/2020 was a ride in the facility van where only residents who had tested negative for Covid-19 were taken on a brief ride to see the beach and then returned to the facility. Staff and the Administrator reported that both staff present during the trip wore masks and all the residents on the trip were given masks to wear but removed them during the field trip. There were two staff members present during the field trip and both reported that during the trip they did not stop the vehicle and the residents did not leave their care. Both staff members stated that they had not tested positive for Covid-19 and always wear masks while working and wore masks for the duration of the resident outing.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 3
Control Number 22-AS-20201209154307
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: 10/26/2023
NARRATIVE
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The Administrator reported that all activities are planned around using the appropriate PPE and following the guidelines set forth by the State and the County. Staff reported that only small cohort groups of four or five residents with the same Covid-19 status participate in activities together. During the 10-day visit LPA observed that all staff were wearing masks at the facility. 3 out of 3 staff interviewed reported always wearing masks while working and during resident activities. 3 out of 3 staff interviewed reported that masks are provided to residents but most of the residents take the masks off and refuse to wear them. It was alleged that the staff led resident outing led to an increase in staff and residents testing positive for Covid-19. There is no way to determine if a resident outing where no one had contact with the public and staff were wearing masks led to an increase in Covid positive staff and residents. In all facilities at the time no visitors were allowed except approved Government workers on official business. Residents could contract Covid-19 from other residents or staff and staff did not live at the facility. There are too many variables and too many cases to determine how each resident tested positive for Covid-19, so it is unreasonable to attribute positive cases of Covid-19 to one incident or trip where none of the people involved had tested positive for Covid-19. None of the evidence gathered supports the allegation. Based on the information gathered, the allegation, facility planned group activities without the proper use of PPE, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, facility failed to cohort Covid positive residents from Covid negative residents, revealed the following. It was alleged that the facility was scheduling Covid-19 positive staff members which put the facility residents at risk. The facility is a memory care only facility. During the month of December 2020 Covid-19 positive cases increased during the month and at one point during the month every resident was positive for Covid-19. On 12/14/2020, the day of the 10-day visit, LPA observed that the residents who had not tested positive were isolated in their rooms because the majority of residents had tested positive for Covid-19. On or around 12/21/2020 all the residents were reported to be positive for Covid-19. During this time, it was allowed for facilities to have Covid-19 positive staff who were asymptomatic to work with residents who were positive for Covid-19. The Administrator reported that they did have Covid-19 positive staff who were asymptomatic work with Covid-19 positive residents only. 3 out of 3 staff interviewed reported that they followed the guidelines set by management and could only work if they had no symptoms and could only work with Covid-19 negative residents if they had tested negative for Covid-19.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20201209154307
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: 10/26/2023
NARRATIVE
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The Administrator reported that as residents were cleared and tested negative for Covid-19 they were isolated in their rooms until the majority of residents were negative for Covid-19. The Administrator reported that at no time were residents of different Covid-19 status allowed to co-mingle. Based on the evidence gathered the allegation, facility failed to cohort Covid positive residents from Covid negative residents, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3