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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 11/13/2025
Date Signed: 11/13/2025 04:26:47 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
11/04/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251104160452
FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:YAYLENE MAZARIEGOSFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 58DATE:
11/13/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Yaylene MazariegosTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff are not abiding to the admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff are not abiding to the admission agreement. During the investigation, LPA conducted interviews with staff and resident in care. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff are not abiding to the admission agreement, it was reported resident 1 (R1) was informed rent is going to increase on January 1, 2026. LPA interview with Admininstrator (AD) Yaylene Mazariegos stated a rate increase letter was issued and provided to R1 on October 22, 2025. LPA interview with R1 stated they received a copy of the rate increase letter. LPA record review revealed R1's admission agreement states on page 11 "We shall give ninety (90) days' prior written notice to you of any change in the Base Monthly Fee..." Continued on LIC9099-C dated 11/13/25
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
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 6
Control Number 22-AS-20251104160452
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 SOUTH COAST
FACILITY NUMBER: 306005272
VISIT DATE: 11/13/2025
NARRATIVE
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R1 is currently not receiving Supplemental Security Income (SSI) based on a letter sent to R1 on June 17, 2025 by the Social Security Administration. The date of the rate increase letter of October 22, 2025 informing R1 of the rate increase starting January 1, 2026 is less than ninety days.

Based on LPA interviews and record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
11/04/2025 and conducted by Evaluator Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20251104160452

FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:YAYLENE MAZARIEGOSFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 58DATE:
11/13/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Yaylene MazariegosTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for a resident
Staff forced a resident to sign an unknown document
Staff inappropriately took pictures of a resident
Staff are not safeguarding a resident's personal phone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged staff did not seek timely medical attention for a resident, staff forced a resident to sign an unknown document, staff inappropriately took pictures of a resident and staff are not safeguarding a resident's personal phone. During the investigation, LPA conducted interviews with staff and residents in care. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation staff did not seek timely medical attention for a resident, it was reported resident 1 (R1) sustained a broken rib and was not taken to the hospital. LPA interviews with three out of three staff stated R1 did not make them aware of any injury to the rib area. LPA interview with R1 stated they have a broken rib and demonstrated the rib area by pushing against their rib cage. Continue on LIC 9099-C dated 11/13/2025.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20251104160452
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 SOUTH COAST
FACILITY NUMBER: 306005272
VISIT DATE: 11/13/2025
NARRATIVE
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R1 stated their rib cage does not hurt and does not know how it could happen. R1 stated there was no fall that would have caused an injury to their rib. R1 added they told one staff member about it but did not want to go to the hospital because "it's too much of a hassle and they make you wait a long time." LPA interviews with three out of three additional residents stated their needs are being met at this time and are receiving medical care as needed. LPA observed R1 readjust from laying on their bed to sitting up on their bed without difficulty. LPA record review revealed R1 has seen outside medical personnel at the facility from July 4, 2025 through November 7, 2025 17 times either by a nurse or physician's assistant. No observations of fractures were noted.

Regarding the allegation staff forced a resident to sign an unknown document, it was reported R1 was forced to sign a document under pressure. LPA interview with Administrator (AD) Yaylene Mazariegos stated AD had R1 sign a copy of the rate increase letter given to R1 on October 22, 2025 to acknowledge a copy was provided. AD provided a copy of the rate increase letter to LPA with R1's signature. LPA interview with R1 stated they vaguely remember signing a copy of the rate increase letter given by AD but not completely sure. R1 stated they received a copy of the rate increase letter.

Regarding the allegation staff inappropriately took pictures of a resident, it was reported on an unspecified date, staff took pictures of client while client was unaware. LPA interviews with three out of three staff stated they are unaware of any staff taking inappropriate pictures of residents. LPA interview with R1 stated they have photos on their phone showing three pictures of R1 from the waist up at an angle coming from the floor as they are walking. R1 stated they are unaware of how those photos came about. LPA observation of the photos appear to be accidental selfies as the photos' angle appear to be coming from R1's left hand at arms length pointing up.

Regarding the allegation staff are not safeguarding a resident's personal phone, it was reported some of R1's pictures have been deleted from their phone. LPA interviews with three out of three staff stated they have never witness anyone deleting pictures from a resident's phone. LPA interview with R1 stated they keep a passcode on the phone and sleep with the phone under their pillow. LPA observed phone securely held in R1's carrying bag with a strap around R1's body.
Continued on LIC9099-C dated 11/13/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20251104160452
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 SOUTH COAST
FACILITY NUMBER: 306005272
VISIT DATE: 11/13/2025
NARRATIVE
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 Based on interviews, record review, and observations, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of the report was left with the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20251104160452
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 SOUTH COAST
FACILITY NUMBER: 306005272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
87507(f)
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87507(f) Admission Agreements
The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
The requirement is not met as evidenced by:
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AD stated a new rate increase letter will be issued to R1 to reflect a 90 notice. AD to send proof to LPA by POC due date.
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The facility did not adhere to a 90 day rate increase notice as indicated in R1's admission agreement which poses a potential personal rights 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6