306005272-4-26-2023-22-AS-SSAS-CT6UM3-20230626154137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:20:16 PM

Substantiated

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
04/18/2023 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230418134043

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:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Stacie Anderson - Executive Director		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff did not administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Executive Director Stacie Anderson.

On today's visit LPA Velazquez reviewed and obtained copies of facility and resident records. LPA Velazquez also conducted interviews with residents and staff. LPA Velazquez reviewed resident records which included Face Sheets, Physician's Reports, Preplacement Appraisal Information, Needs and Services Plans, Power of Attorney documents, Resident Assessments, Medication Sheets, and an Admissions Agreement. At 10:35 AM LPA Velazquez along with Resident Care Director Jennifer Thompson, L.V.N. conducted a review of medications for 3 residents. LPA Velazquez and RCD Thompson observed the following for Resident (R) #1: Myrbetriq ER 25 mg was listed on the Medication Sheet but the medication was not present in the facility at the time of this visit and resident was not given today's dose as prescribed which RCD Thompson confirmed. R1

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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-20230418134043

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: 04/26/2023

NARRATIVE

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also had Vitamin B-12 1000 mcg present in the facility but it was not documented on R1's Medication Sheet which RCD Thompson confirmed. RCD Thompson provided a copy of R1's physician's order and indicated that the B-12 is being administered to R1 as prescribed by their doctor.
R2 has Rybelsus 3 mg documented on their Medication Sheet but R2 was not given this medication this morning because per RCD Thompson the medication ran out but it has been ordered and is expected to arrive some time today. Two of two individuals interviewed confirmed the medications for R1 and R2 were not administered today as prescribed by their doctors as the aforementioned medications were not present in the facility at the time of this visit.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff did not administer resident's medication as prescribed is 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 Executive Director Stacie Anderson and a copy of this report along with the appeal rights, LIC 811, and LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230418134043

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: 04/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/27/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. If the resident's physician... provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure all medications are given in accordance to doctor's orders at all times. Licensee to obtain the missing medications for R1 and R2 and submit written proof to LPA by POC due date.
	8 9 10 11 12 13 14	based on record review and interview the Licensee did not ensure the medications for R1 and R2 were given according to physician's orders. This poses an immediate risk to the health & safety of residents in care.	8 9 10 11 12 13 14	Licensee to submit a written statement to LPA indicating they have read this section of regulation and how they intend to adhere to it by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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