306004640-3-12-2025-22-AS-LMOA-DER5HA-20250313195759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004640
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:32:45 PM

Substantiated

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
10/23/2024 and conducted by Evaluator Jenifer Tirre

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241023094545

FACILITY NAME:	PACIFICA SENIOR LIVING NEWPORT MESA		FACILITY NUMBER:	306004640
ADMINISTRATOR:	STACIE ANDERSON		FACILITY TYPE:	740
ADDRESS:	2891 BEAR ST		TELEPHONE:	(949) 629-1020
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	40	CENSUS: 22	DATE:	03/12/2025
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Executive Director, Rose Nakadaira		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not ensure that modified diets prescribed by a resident's physician as a medical necessity was provided.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jenifer Tirre met with Executive Director Rose Nakadaira and Memory Care Director Amy Kaplli for the purpose of delivering findings for the above allegations. The complaint consisted of interviews, record review, and observations.
On October 23, 2024 the department received allegations that facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided. The investigation was completed by the Department and revealed the following:

Based off interviews with staff, eight out of eight staff interviewed stated that they were all aware Resident 1 (R1) had a special pureed diet. Six of eight staff stated that they are notified of diet and or medication changes via a group chat that is sent out via text message to staff phones. Five of eight staff were aware that R1 had an incident where they were not given a pureed meal and aspirated on food. Three of eight staff members interviewed stated that R1 was fed meal by staff 1 (S1) where R1 aspirated and stated that S1 did not review group message that was sent out regarding R1’s puree diet.
CONTINUED ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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 3

Control Number 22-AS-20241023094545

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 SENIOR LIVING NEWPORT MESA	FACILITY NUMBER: 306004640
	VISIT DATE: 03/12/2025

NARRATIVE

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Two of eight staff stated that S1 has a history of being out of compliance at work and not following directions. Interview with kitchen staff confirmed that facility has a binder for residents who have special diets that gets updated when changes are made.

Based off records review, an incident report dated 10/11/2024 states that R1 was fed eggs by S1 and aspirated. Incident Report states that 911 was called and resident taken to hospital. Narrative Charting notes dated for 10/15/2024 stated that R1 was aspirating during dinner, 911 was called and paramedics arrived and suction R1. Record review of menu for October 11, 2024 for breakfast was Sausage Link, choice of cereal, pancakes and choice of juice. Menu did not match what witness reported R1 eating that day. Staff Schedule does confirm that S1 was working AM shift on October 11, 2024. Residents Physician’s Report dated 9/6/24, Preplacement Appraisal dated 9/9/24, and Needs & Service Plan dated 9/13/24 all state that R1 has a pureed diet with thickened liquids, water and Juice. Needs & Service plan states that “Residents goals for meals are to maintain adequate nutritional intake and allow enough time for resident to eat at a comfortable pace”. Preplacement Appraisal states under services needed, resident has special diet and observation of food intake. Collective Hospice Care Documents Revealed that R1 was admitted under Hospice Care on 10/16/2024.

During initial visit on 10/30/2024, during facility tour LPA Tirre observed the following during visit: LPA reviewed Board in Kitchen with names of residents on special diets and observed that R1 was missing from board. LPA also attempted to view kitchen binder that has special diet orders for residents and was informed that a staff member borrowed binder and had not returned. LPA observed R1 to be sleeping in bedroom during visit and was unable to interview.

Based on interviews, records reviewed and observations the preponderance of evidence has been met, deeming the allegations Facility did not ensure that modified diets prescribed by a resident’s physician as a medical necessity was provided is deemed SUBSTANTIATED.

The following deficiencies are being cited per Title 22. A exit interview was conducted with Executive Director Rose Nakadaira. A copy of this report, confidential names list and appeals right was provided to facility.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20241023094545

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 SENIOR LIVING NEWPORT MESA	FACILITY NUMBER: 306004640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/13/2025 Section Cited CCR 87705(b)(1)(8)	1 2 3 4 5 6 7	87705 Care of person with Dementia(b) Licensees shall be responsible for the following: (1) ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (B) Recognizing symptoms that may create or aggravate behavioral	1 2 3 4 5 6 7	Licensee to provide updated policy on Special diets & Activities of Daily living for residents and provide in service training with signatures of staff. Licensee to provide plan of correction by due date 3/13/2025.
	8 9 10 11 12 13 14	expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, UTI's, and problems with swallowing.This requirement was not met as evidenced by R1 was fed solid food and aspirated when physician’s report, appraisal and needs & service plan stated R1 was on a special pureed diet. This poses an immediate health, safety and or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC9099 (FAS) - (06/04)

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