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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:46:26 PM

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
09/13/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220913103113
FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 48DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Stacie Anderson - Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident suffered from dehydration while in care
Resident fell while in care
Resident is not provided a comfortable temperature
Facility does not have adequate drinking supplies
Staff are not following posted activities schedule
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings into the above allegations. LPA Velazquez was allowed entry into the facility and met with Executive Director Stacie Anderson and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and requested copies of facility and resident records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility and resident records. The records reviewed included Resident Face Sheets, Physician's Reports, Internal Incident Reports, Needs and Services Plans, Resident Narrative Charting Notes, Resident Assessments, Activities Calendars, pictures of various activities dated October 2022 - February 2023 where residents have participated that have been posted on the facility's social media page, and Resident (R) #1's Hoag Hospital Emergency Center records for a visit dated August 16,2022.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 4
Control Number 22-AS-20220913103113
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: 03/09/2023
NARRATIVE
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Ten of ten individuals interviewed provided conflicting statements and could not corroborate the allegations. Per ED Anderson, residents at times fail to sign up for specific activities and have to be canceled due to lack of participation. During the initial complaint visit and during today's visit LPA Velazquez observed different beverage stations throughout the facility. During the resident interviews conducted today, LPA Velazquez also observed each resident had water present within reach and others had several water bottles in their rooms. The 6 residents interviewed felt they were well-cared for here at the facility with the temperature in their rooms described as comfortable.




Based on the observations made, interviews which were conducted and the records that were reviewed, 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, therefore the following allegations: Resident suffered from dehydration while in care, Resident fell while in care, Resident is not provided a comfortable temperature, Facility does not have adequate drinking supplies, and Staff are not following posted activities schedule are all deemed UNSUBSTANTIATED.

An exit interview was conducted with Business Office Manager Daniel Remus Marante and a copy of this report along with the LIC 811 was provided at the time of this visit.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
09/13/2022 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220913103113

FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 48DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Stacie Anderson - Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Air conditioner is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced subsequent complaint visit to deliver the findings into the above allegations. LPA Velazquez was allowed entry into the facility and met with Executive Director Stacie Anderson and explained the purpose of the visit.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and requested copies of facility records. During the course of the investigation the following was revealed: LPA Velazquez conducted interviews with residents and staff. Records reviewed included invoices for repair of the facility's furnace and AC units. Ten of ten individuals interviewed provided conflicting statements and could not corroborate the above allegation. Based on LPA's observations, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: is/are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with Business Office Manager Daniel Remus Marante and a copy of this report along with the Appeal Rights was provided at the time of this visit.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 4
Control Number 22-AS-20220913103113
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: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: based on interview and record review the facility did not
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Licensee to ensure the furnace and AC units are in operating condition at all times. The furnace and AC units have been repaired and all is in working order as of this visit.

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ensure the furnace and AC units were in operating condition. This poses a potential risk to the health and safety of residents in care.
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THE CITATION IS NOW CORRECTED AND CLEARED. Clearance letter provided at the time of this visit.
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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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4