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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 03/12/2025
Date Signed: 03/12/2025 12:43:02 PM

Unfounded


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
01/25/2021 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210125155304
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: 34DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Yaylene MazariegosTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff prevented resident's medical professional from caring for resident.
Facility did not provide resident's authorized representative with written refund policy in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met Executive Director (ED) Yaylene Mazariegos.

It is alleged staff prevented Resident 1’s (R1’s) medical professional from caring for R1. Inteviews were conducted with four facility residents, one witness, and R1’s Responsible Party (RP). R1 could not be interviewed as they have since passed away. During their interview, R1’s medical professional, Witness 1 (W1) stated they were never denied visitation or access to R1 by the facility or its' staff, and stated the facility staff was very receptive during the time they cared for R1. During their inteview, R1's RP denied having any knowledge of staff preventing R1's medical professional from caring for R1. During today’s visit, four additional facility residents were interviewed; four of four residents denied staff preventing medical professionals from caring for them, (Cont. LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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-20210125155304
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: 03/12/2025
NARRATIVE
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It is alleged facility did not provide R1's authorized representative with written refund policy in a timely manner. During their interview, R1’s RP denied the facility not providing them with written refund policy in a timely manner. LPA also obtained and reviewed a copy of R1's facility refund agreement signed and dated December 16, 2019.

The Department has investigated the complaint alleging staff prevented resident's medical professional from caring for resident and facility did not provide resident's authorized representative with written refund policy in a timely manner. After interviews conducted with facility residents, witness, and R1's RP, 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.

An exit interview was conducted and a copy of this report was provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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
01/25/2021 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20210125155304

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: 34DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Yaylene MazariegosTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident in a timely manner.
Staff did not safeguard resident's personal belongings.
Facility did not answer communications from authorized representative promptly.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Yaylene Mazariegos and explained the purpose of the inspection.

It is alleged staff did not seek medical attention for Resident 1 (R1) in a timely manner. Interviews were conducted with R1’s Responsible Party (RP), three facility staff, and four residents. R1 could not be interviewed as they have since passed away. During their interview, RP stated that two weeks prior to R1’s death on January 17, 2021, R1 had tested positive for COVID and had initially been asymptomatic. Per RP, at the time R1 had indicated to them that they were fine. RP stated two days prior to his death, R1 was found unresponsive by facility staff and RP was informed of R1’s hospitalization due to complications from COVID. Per RP, the facility "did the best they could" given the circumstances at the time during the pandemic, and stated they had "no ill feelings" towards the facility or staff. (Cont. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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-20210125155304
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: 03/12/2025
NARRATIVE
1
2
3
4
5
6
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8
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Four of four residents interviewed were unable to corroborate allegation and stated they receive medical attention as needed and in a timely manner. Three of three staff interviewed denied medical attention being delayed or denied to any resident and stated medical attention is sought in a timely manner for all residents.

It is alleged staff did not safeguard R1’s personal belongings. Interviews were conducted with R1’s RP, three facility staff, and four residents. During their interview, RP stated that R1's Ipad was stolen at the facility and was never recovered. Three staff of three staff interviewed denied having any knowledge of R1’s Ipad being stolen and stated missing property or valuables have not been reported by any other resident or their responsible party. Four of four residents interviewed could not corroborate the allegation and denied having any missing property or valuables.

It is alleged facility did not answer communications from R1’s authorized representative promptly. Interviews were conducted with R1’s RP, three facility staff, and four residents. During their interview, RP stated that due to the pandemic, they were unable to visit R1 and there were days when they were unable to get a hold of R1 by phone. RP stated R1 had a phone and knew how to use it, however R1 was also hard of hearing and would often go without answering their phone because they could not hear it. Per RP, the facility for their part was responsive and they did not have any concerns. Three staff of three staff interviewed denied allegation and stated there is ongoing communication between the facility and residents’ authorized representatives, if any. Four of four residents interviewed also denied the allegation and stated the facility and facility staff have ongoing communication with their authorized representatives.

Due to conflicting information received during interviews conducted, LPA is unable to determine if staff did not seek medical attention for resident in a timely manner, if staff did not safeguard resident's personal belongings, or if the facility did not answer communications from authorized representative promptly. Although the above 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 at this time the above allegations are unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4