306005272-12-21-2023-22-AS-AORZ-DB8QJY-20241121111331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:47:36 PM

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
09/27/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230927162232

FACILITY NAME:	PACIFICA SENIOR LIVING SOUTH COAST		FACILITY NUMBER:	306005272
ADMINISTRATOR:	STACIE ANDERSON		FACILITY TYPE:	740
ADDRESS:	2619 ORANGE AVE		TELEPHONE:	(949) 515-0121
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	98	CENSUS: 33	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Community Relations Director- Kimberly Melendez Business Office Manager - Yesenia Castro		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following infection control protocols.
Facility staff are not properly trained.
Facility does not provide activities to residents.
Lack of care and supervision.
Facility is understaffed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings for the complaint received on 9/27/2023. LPA De Perio explained the purpose of today's visit, was greeted by Community Relations Director (CRD) Kimberly Melendez and Business Office Manager (BOM) Yesenia Castro. Facility administrator was unable to be present during today’s visit.

It was alleged that facility is not following infection control protocols. LPA De Perio conducted a total of 9 interviews, of which all 6 resident interviews, and all 3 staff interviews did not corroborate with the allegation by stating that the facility does follow infection control protocols. During the tour of the physical plant of the facility, LPA De Perio observed that the facility has an adequate supply of PPE such as disinfectants, gowns, masks and gloves. Per documentation review, the facility has an Infection Control Plan that is implemented and utilized if a resident has tested positive for COVID.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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-20230927162232

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 SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 12/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was alleged that the facility staff are not properly trained. LPA De Perio conducted a total of 9 interviews, of which all 6 resident interviews, and all 3 staff interviews did not corroborate with the allegation. All 6 resident interviews also confirmed that there were no health or safety concerns regarding staff and their training. Per documentation review, each staff member undergoes training that consists of hands-on orientation and shadowing, video tutorials, completion of tests and certifications.

It was alleged that the facility does not provide activities to residents. LPA De Perio conducted a total of 9 interviews, of which all 6 resident interviews, and all 3 staff interviews did not corroborate with the allegation. During the tour of the physical plant of the facility, LPA De Perio observed that there is an activity calendar posted in the hallway of the facility and at the front desk for the entirety of the month. Per activity calendar, there are ongoing daily activities both in the assisted living and memory care portion of the facility, and is led by the facility activities director. Per documentation review, LPA De Perio observed photos of residents engaging in activities at the facility such as participating in games, pet therapy, arts and crafts, music, and outdoor activities.

It was alleged that there is lack of care and supervision. LPA De Perio conducted a total of 9 interviews, of which all 6 resident interviews, and all 3 staff interviews did not corroborate with the allegation. 4 of the resident interviews specified about how “great” the staff was and disclosed their satisfaction with the facility. Per documentation review, it was observed that if a resident needs medical care or an evaluation, the facility contacts the resident’s medical team in a timely manner. 1 interview conducted with staff also specified that regardless of the staff’s position, each staff is trained on caring for a resident, reporting requirements and trained on obtaining medical assistance.

It was alleged that facility is understaffed. LPA De Perio conducted a total of 9 interviews, of which all 6 resident interviews, and all 3 staff interviews did not corroborate with the allegation. All 3 staff interviews and 2 resident interviews specified that if there is a call-out for a care staff, the facility administrator, Health and Wellness director, or additional personnel with the qualifications, will obtain the shift to ensure coverage is met in the area needed. Per documentation review of the staff schedule, and monthly schedule from August 2023 to October 2023, LPA observed that there was a minimum of 2 caregivers, 2 med-techs, and 1 nurse, per shift. For night supervision, it was also observed that there is a designated staff member on-call to attend to the facility if needed.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230927162232

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 SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 12/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED.

An exit interview was conducted with CRD Melendez and BOM Castro.

A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3