306005272-7-10-2026-22-AS-SSAS-DW3Q5U-20260717115233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 07/10/2026
Date Signed: 07/10/2026 03:40:43 PM

Unsubstantiated

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
05/12/2026 and conducted by Evaluator Garlli Tat

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260512163418

FACILITY NAME:	PACIFICA SENIOR LIVING SOUTH COAST		FACILITY NUMBER:	306005272
ADMINISTRATOR:	YAYLENE MAZARIEGOS		FACILITY TYPE:	740
ADDRESS:	2619 ORANGE AVE		TELEPHONE:	(949) 515-0121
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	98	CENSUS: 70	DATE:	07/10/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	David Hernandez		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulted in resident sustaining unspecified injuries.
Staff did not meet a resident bathing and incontinence needs.

INVESTIGATION FINDINGS:

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On July 10, 2026, Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with the Resident Service Coordinator, Carmen Velasco and explained the purpose of the visit.

An initial complaint investigation visit took place on May 19, 2026. During the visit, LPA accompanied by Executive Director conducted a tour of the facility's physical plant. LPA requested and obtained the resident and staff roster, face sheet, medical assessment, POLST, admission agreement, shower log, preplacement appraisal, physician’s orders, and shower body check form. Five staff and seven resident interviews were conducted during the visit.

The investigation revealed the following: Regarding the allegation that neglect/lack of care and supervision resulted in resident sustaining unspecified injuries, it was reported that skin tears were not reported and hospice was not followed up on for Resident 1 (R1). Continued on LIC-9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260512163418

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: 07/10/2026

NARRATIVE

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Per R1’s LIC602, there was no mention of hospice being recommended. Five out of five staff stated R1 was not on hospice. LPA reviewed R1’s head-to-toe assessment dated April 3, 2026, and photos of bruises on R1’s legs and arm. Per shower body check forms dated April 7, April 10, April 17, April 21, April 24, April 28, May 1, and May 5, 2026, no abnormalities on the skin were noted by caregiver. Photographic evidence shows bruise on left calf and bruise on right arm when they moved in. LPA also reviewed photographic evidence of swollen feet, cracked nails, and a scab. Three out of five staff interviewed, corroborated that R1 had swollen feet and reported the incident. Per physician’s orders dated May 15, 2026, Amoxicillin 125mg oral tablets were prescribed for R1. Five out of seven residents, including R1 stated they had never sustained injuries due to lack of care. None of the evidence gathered supports the allegation.

Regarding the allegations that staff did not meet a resident’s bathing and incontinence needs, it was reported that showers are not being provided as agreed upon and resident was found in feces and soiled diapers. R1 requires assistance with bathing and toileting. Per records review, R1 showered at least once a week. Five out of seven residents interviewed, including R1, denied the allegation. Two residents interviewed could not provide any details regarding the allegation and responded with unrelated information. Four out of five staff interviewed denied the allegation. One out of five staff interviewed confirmed the allegation.

Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the report was provided to a facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026

LIC9099 (FAS) - (06/04)

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