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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 01/25/2021
Date Signed: 01/25/2021 03:12:50 PM



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
02/07/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200207101610
FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:MAUREEN SALONGAFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 39DATE:
01/25/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Stacie AndersonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not seek medical treatment for resident in a timely manner
Staff make inappropriate comments to residents
Staff blocked exits with furniture
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Administrator Stacie Anderson via facetime due to COVID-19 precautionary measures to discuss the findings for the above allegations. Ms. Anderson became the Administrator 6/1/20. The allegations were investigated by the Department. The investigation consisted of interviews conducted with the facility staff, Administrator, and witnesses as well as documentation. The following was determined:

The Department received a complaint regarding allegations of the staff failing to seek medical attention for the resident in a timely manner and that staff were blocking exits with furniture.

On 11/13/19 at approximately 10:05pm staff confirmed that Resident #1(R1) was found in bed screaming for help. R1 had extensive skin tears with bleeding on his left upper arm and left arm below the elbow. R1 was also complaining of pain in his left hip. Although staff stated that the injuries were unwitnessed, it was clear that R1 suffered a fall or some other accident causing the injuries. First aid was given to R1 and Tylenol was
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
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 7
Control Number 22-AS-20200207101610
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: 01/25/2021
NARRATIVE
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given for pain. R1 was monitored throughout the night and was sent to the hospital the next morning due to being lethargic and pale. R1 was diagnosed with a closed left hip fracture along with other ailments. Based on R1’s injuries, 911 should have been called immediately. Staff failed to seek medical attention in a timely manner.

Interviews with staff and the Executive Director disclosed that Staff #1 made inappropriate comments to residents and that the memory care staff created barriers in front of the courtyard door. The barriers were created to prevent residents from leaving and entering the courtyard. Disciplinary action was taken with Staff #1 and all staff involved.

The Department has substantiated the above noted complaint allegations as valid, and a violation has occurred based on the preponderance of available evidence. A copy of this LIC 9099 and LIC 9099D report along with appeal rights are being reviewed with facility administrator and a copy is being furnished.

*A Civil Penalty assessment accompanies the deficiency

A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). For a violation that the department determines constitutes physical abuse as defined in Section 15610.63 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).


An exit interview was conducted and appeal rights were discussed with Administrator Stacie Anderson. A copy of this report was provided via email for review and signature. A hard copy will be kept on file.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20200207101610
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2021
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care Needs- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis.
This requirement was not met as evidenced by:
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Administrator agreed that a staff meeting will be held with all staff regarding resident injuries and 911 protocols. An agenda and sign in sheet will be provided to the Department.
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On 11/13/19, staff failed to immediately telephone 911 when R1 was found screaming in his bed with bleeding from his arm and complaining of hip pain.
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Type A
01/26/2021
Section Cited
CCR
87468.1(a)(3)
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Personal Rights-Residents in all residential care facilities for the elderly shall be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions.This requirement was not met as evidenced by:
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Administrator stated corrective action was taken with Staff #1 and agreed to conduct a staff meeting regarding resident rights. Proof of meeting shall be provided via agenda and sign in sheet.
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Interviews with witnesses disclosed that Staff #1 would make inappropriate comments to residents.
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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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20200207101610
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2021
Section Cited
CCR
87203
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Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement was not met as evidenced by:

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Administrator stated that staff involved were disciplined for blocking the exit to the courtyard and agreed to have a staff meeting regarding blocking exits and violating resident rights. Proof that a staff meeting was held will be provided to the Department with an agenda and sign in sheet.
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Interviews with staff disclosed that memory care staff would create barriers in front of the courtyard door to prevent residents from leaving and entering the courtyard.

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CCR
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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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
02/07/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200207101610

FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:MAUREEN SALONGAFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: DATE:
01/25/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Stacie AndersonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
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9
Neglect and lack of supervision resulted in R1 falling and breaking hip
Insufficient staffing to meet resident's needs
Residents wandered out of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Administrator Stacie Anderson via facetime due to COVID-19 precautionary measures to discuss the findings for the above allegations. Ms. Anderson became the Administrator 6/1/20. The allegations were investigated by the Department. The investigation consisted of interviews conducted with the facility staff, Administrator, and witnesses as well as documentation. The following was determined:

The Department received a complaint regarding allegations that there was insufficient staffing and that neglect, and lack of supervision led to R1 falling and fracturing his hip. Allegations further allege that resident’s wander out of the facility.

On 11/13/19 at approximately 10:05pm staff confirmed that Resident #1(R1) was found in bed screaming for help. R1 had extensive skin tears with bleeding on his left upper arm and left arm below the elbow. R1 was also complaining of pain in his left hip. Interviews and records review disclosed that R1 was a fall risk. R1
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20200207101610
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: 01/25/2021
NARRATIVE
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wore a pendant around the neck and was instructed to use it when getting out of bed. R1's room and bathroom were also equipped with call alarms to call for staff assistance. When R1 would call for assistance, 1-2 staff members would assist him out of bed to his wheelchair. R1 always used a wheelchair to get around the facility and always with a staff escort. R1 always had two staff members assist with showering. There were no fall mats in R1’s room. R1 was checked by staff at least four times a day. It is believed R1 fell on 11/13/19 to cause R1’s injuries, but it was unwitnessed. R1 has had no prior falls at the facility. The Department did not find any witnesses or evidence to corroborate the allegation of neglect and supervision.

Based upon a review of staff schedules over a period of 4 months, there were no changes in staffing as each shift appeared to have had enough staff based on census. Based on interviews with staff and residents, with the exception of reporting party, all stated that the facility schedules staff based on census and there has been no changes in staffing Residents interviewed stated that although there may be times when staff are tending urgent matters and cannot respond immediately, residents interviewed stated they felt their needs were being met with the number of staff scheduled.

Reporting party stated that residents are wandering out of the memory care portion of the building. Per interviews residents have the right to enter the courtyard off of the memory care unit. There is delayed egress on door which leads to the courtyard, in addition there are delayed egress on the gates which lead out of the court yard. The purpose of delayed egress is to notify staff that a resident has entered courtyard.

Based upon interviews and a review of R1's records, these allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted with Administrator Stacie Anderson and a copy of this report was provided via email for review and signature. A hard copy will be kept on file.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
02/07/2020 and conducted by Evaluator Michelle Reed
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200207101610

FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:MAUREEN SALONGAFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: DATE:
01/25/2021
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator Stacie AndersonTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff did not report an unusual incident
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michelle Reed met with Administrator Stacie Anderson via facetime due to COVID-19 precautionary measures to discuss the findings for the above allegations. Ms. Anderson became the Administrator 6/1/20. The allegations were investigated by the Department. The investigation consisted of interviews conducted with the facility staff, Administrator, and witnesses as well as documentation. The following was determined:
On 11/13/19 R1 was found in bed with skin tears and complaining of hip pain. Incident reports submitted to Licensing from the facility were reviewed. An unusual incident was submitted to the Department on 11/15/19. R2’s records and medications were reviewed. The allegation is that R2 was given Tylenol and had an allergic reaction. There is no documentation to prove that R2 was allergic to Tylenol. Executive Director Maureen Solonga stated that R2 did not have an allergic reaction to medication.
This agency has investigated these complaint allegations. We have found that the complaint was unfounded, meaning that the allegations are false, could not have happened and/or are without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Administrator Stacie Anderson and a copy of this report was provided via email for review and signature.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 748-2936
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7