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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 05/26/2026
Date Signed: 05/26/2026 04:25:21 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
03/16/2026 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260316142102
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: 69DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director Yaylene MazariegosTIME COMPLETED:
04:40 PM
ALLEGATION(S):
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9
Staff did not ensure medication was stored locked and inaccessible to residents
Staff did not dispense medications to residents as prescribed
Unqualified staff administer injections to residents
INVESTIGATION FINDINGS:
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13
On May 26, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Yaylene Mazariegos was present and also assisted on today's visit.

During the course of the investigation, LPA interviewed resident and interviewed staff. LPA also reviewed and obtained pertinent documents to this complaint such as resident records, including medication administration records. Regarding the allegation, staff did not ensure medication was stored locked and inaccessible to residents, the following has been concluded: During the course of the investigation, LPA inspected the facility's medication room and ten resident bedrooms. During a tour of Resident #1 (R1's) bedroom, R1 disclosed that she stores her insulin injection in her refrigerator. LPA then observed an insulin injection pen to be stored in R1's refrigerator which is kept unlocked and accessible to R1. LPA also observed that the door leading to R1's bedroom is also kept unlocked. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
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-20260316142102
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: 05/26/2026
NARRATIVE
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LPA reviewed the Physician's Report for R1 dated June 2, 2025, which states that R1 is unable to manage her own prescription medications and is unable to store her own medications. Therefore, R1's insulin injection pen should be kept locked an inaccessible to R1. LPA conducted seven staff interviews. Four out of the seven staff interviewed corroborated the allegation and confirmed that R1's insulin injection pen is kept in R1's refrigerator. The four staff also confirmed that R1's refrigerator is not kept locked and is accessible to R1 at any time.

Regarding the allegation, staff did not dispense medications to residents as prescribed, the following has been concluded: LPA conducted ten resident interviews. Eight out of the ten residents interviewed denied the allegation and reported no issues with their medications. The other two residents were unable to provide any useful information for this allegation. The Department conducted seven staff interviews. Six out of the seven staff interviewed denied the allegation. However, one staff interviewed corroborated the allegation. During the course of the investigation, LPA reviewed the medication and medication administration records nine residents of the facility. LPA observed the facility did not the following as needed medications for Resident #2 (R2): Acetaminophen 325 MG tablet, Benzonate 100 MG capsule, Geri-Lanta Liquid, and Milk of Magnesia suspension. All the medications listed were not present at the facility if R2 required it, despite it being listed under R2's active medication orders. LPA observed the facility did not have the following as needed medications for Resident #3 (R3): Geri-Lante Liquid, Loperamide 2 MG capsule, and Milk of Magnesium. All the medications listed were not present at the facility if R3 required it, despite it being listed under R3's active medication orders. LPA observed the facility did not have the following as needed medication for Resident #5 (R5): Cetirizine 10 MG tablet. The medication listed was not present at the facility if R5 required it, despite it being listed under R5's active medication orders. LPA observed the facility did not have the following as needed medication for Resident #6 (R6): Robafen liquid. The medication listed was not present at the facility if R6 required it, despite it being listed under R6's active medication orders. LPA observed the facility also did not have the following as needed medication for Resident #9 (R9): Milk of Magnesia Suspension. The medication listed was not present at the facility if R9 required it, despite it being listed under R9's active medication orders. LPA conducted ten resident interviews.

Regarding the allegation, unqualified staff administer injections to residents, the following has been concluded: It was alleged that unqualified staff administer injections to R1. LPA reviewed the Physician's Report for R1 dated June 2, 2025, which states that R1 is Type 2 Diabetic. CONTINUED ON LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20260316142102
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: 05/26/2026
NARRATIVE
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It also states that R1 is unable to manage her own medication and is unable to administer her own prescription medications. LPA reviewed the medication orders for R1 which states that R1 requires a Lantus Solostar 100 unit milliliter injection daily. LPA conducted an interview with R1. R1 stated that she is not able to do her own injections, and R1 identified three staff who have done the injections for her previously. During the investigation, the Department obtained admission from three separate staff who stated that they have given injections to R1, and have observed other staff give injections to R1.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the three allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegation are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted with Executive Director Yaylene Mazariegos. A copy of the report and appeal rights were provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Citations on this Visit Report are Under Appeal!

Control Number 22-AS-20260316142102
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: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/27/2026
Section Cited
CCR
87465(h)(2)
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7
87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...
This requirement is not evidenced by:
1
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The Executive Director stated that she will centrally store R1's medication. The Executive Director stated that she will also conduct an in service training with staff regarding the storage of medication. The Executive Director agreed to provide LPA proof of training via email or fax by POC
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Based on interviews and records reviewed, the Licensee did not ensure that R1's medications were stored in a safe and locked place, due to R1 not being able to store her own medication per her Physician's Report. This poses an immediate health and safety risk to persons in care.
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due date.
Under Appeal
Type A
05/27/2026
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed...(5) Facility staff, except those authorized by law, shall not administer injections..
This requirement is not evidenced by:
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The Executive Director stated that she create a plan to ensure that injections are only administered to R1 by a medical professional. The Executive Director stated that she will also conduct an in service training with staff regarding injections. The Executive Director agreed to provide LPA
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Based on interviews conducted, the Licensee did not ensure that a medical profession administered injections to R1. LPA received an admission from R1 and three staff who corroborated the allegation. This poses an immediate health and safety risk to persons in care.
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the plan and the in service training via email or fax by POC due date.
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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20260316142102
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: 05/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2026
Section Cited
CCR
87465(a)(5)
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3
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7
87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not evidenced by:
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The Executive Director stated that she will either discontinue the as needed medications, or order refills for them to be present at the facility. The Executive Director also stated that she will conduct an in service training with staff regarding medication management. The Executive Director agreed to provide LPA
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Based on records reviewed, the Licensee did not ensure that each resident's as needed medications were present at the facility if needed by the resident. This poses a potential health, safety, and personal rights risk to persons in care.
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proof of the in service training via email or fax by POC due date.
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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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
03/16/2026 and conducted by Evaluator Brandon Lopez
COMPLAINT CONTROL NUMBER: 22-AS-20260316142102

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: 69DATE:
05/26/2026
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director Yaylene MazariegosTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not accurately record residents' medication log
Staff did not assist residents in a timely manner
Staff did not meet residents’ incontinence needs
Facility's air conditioner is not operational
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On May 26, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Yaylene Mazariegos was present and also assisted on today's visit.

During the course of the investigation, LPA interviewed resident and interviewed staff. LPA also reviewed and obtained pertinent documents to this complaint such as resident records. Regarding the allegation, staff did not accurately record residents' medication log, the following has been concluded: During the course of the investigation, LPA reviewed the medication and medication administration records for nine residents. LPA did not observe, and was unable to gather any evidence of residents' medication logs not being recorded accurately. LPA conducted seven staff interviews. One out of the seven staff interviewed corroborated the allegation. However, six out of the seven staff interviewed denied the allegation and reported no issues with resident's mediction logs. CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20260316142102
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: 05/26/2026
NARRATIVE
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Regarding the allegation, staff did not assist residents in a timely manner, the following has been concluded: During the investigation, LPA observed that the facility's call button and call cord system does not document the time that it takes for staff to respond to resident's calls. LPA conducted ten resident interviews. Three out of the ten residents interviewed corroborated the allegation and reported that they have had issues with staffing not responding to them timely due to staffing issues. However, seven residents interviewed either denied the allegation or were unable to provide any useful information. LPA conducted seven staff interviews. One out of the seven staff interviewed corroborated the allegation. However, six out of the seven staff interviewed denied the allegation.

Regarding the allegation, staff did not meet residents’ incontinence needs, the following has been concluded: LPA conducted ten resident interviews. Only four out of the ten residents interviewed stated that they require assistance with incontinence care. Two residents corroborated the allegation and reported issues with receiving incontinence care. However, two residents also denied the allegation and reported no issues with their incontinence care. LPA conducted seven staff interviews. One out of the seven staff interviewed corroborated the allegation. However, six out of the seven staff interviewed denied the allegation.

Regarding the allegation, facility's air conditioner is not operational, the following has been concluded: During LPA's visits to the facility on March 20, and May 12, 2026, LPA observed the facility air conditioner to be operational. LPA conducted ten resident interviews. Four out of the ten resident's interviewed corroborated the allegation and reported previous issues with the facility's air conditioner. However, six residents either denied the allegation or were unable to provide any useful information. LPA conducted seven staff interviews. Two out of the seven staff interviewed corroborated the allegation. However, five staff interviewed denied the allegation and reported no issues with the facility's air conditioner.

Based on the evidence gathered during the investigation, the Department 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 violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Yaylene Mazariegos. A copy of the report was provided to the facility at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7