306005272-1-18-2023-22-AS-LADS-CNETAX-20230125133416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 01/18/2023
Date Signed: 01/18/2023 10:32:35 AM

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
11/07/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221107103548

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: 43	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Memory Care Director-Jennifer Thompson		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Facilities elevator's permit is expired

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Memory Care Director Jennifer Thompson and stated the purpose of this visit which was to deliver the final findings for the complaint received on 11/7/22 against this facility.

This agency has investigated the complaint alleging that facilities elevator's permit is expired. LPA De Perio conducted interviews and record reviews, of which all stated that facility has contacted the city for a permit renewal, however per city council, there is a backlog of renewing the elevator permits. Facility conducts monthly maintenance checks for elevators, of which all inspections dated from March 2022 to December 2022 have been passed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

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: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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

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
11/07/2022 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221107103548

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: 43	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Memory Care Director-Jennifer Thompson		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Facility is not allowing residents to pick their own pharmacy
Facility is not providing transportation to medical appointments per admissions agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Memory Care Director Jennifer Thompson and stated the purpose of this visit which was to deliver the final findings for the complaint received on 11/7/22 against this facility.

This agency has investigated the complaint alleging that facility is not allowing residents to pick their own pharmacy. LPA De Perio conducted record reviews and interviews and found that facility collaborates with Buy Rate pharmacy, and facility recommends residents to utilize partnering pharmacy, however, resident/responsible parties are free to decline facility pharmacy, and if so, the individual is required to sign a form declining use of pharmacy. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

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: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20221107103548

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: 01/18/2023

NARRATIVE

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This agency has investigated the complaint alleging that facility is not providing transportation to medical appointments per admissions agreement. LPA De Perio conducted interviews and record reviews, which stated that facility does provide transportation to medical appointments per admission agreements. All the interviews conducted stated that facility administrator, and memory care director are the designated staff members who take residents to and from their appointments. No resident appointments have been missed, unless a resident has requested to reschedule. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

For this visit, no citations were issued. No deficiencies issued. LPA De Perio conducted an exit interview with Memory Care Director Thompson and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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