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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 03/21/2025
Date Signed: 03/21/2025 04:06:16 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
03/13/2025 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20250313151337
FACILITY NAME:PACIFICA SENIOR LIVING SOUTH COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:PATRICK MCADOO-MORTONFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 34DATE:
03/21/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yaylene Mazariegos- Executive Director TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility does not have adequate staffing.
Facility does not provide adequate hygiene supplies.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an uannnouced visit to conduct a complaint investigation. LPA was greeted and granted entry into the faciliy by Executive Director Yaylene Mazariegos and explained the reason for the visit.

The Department received the complaint on 03/13/2025 and LPA Mendivil conducted the initial 10 day visit on 03/21/2025. LPA Mendivil toured facility and interviewed residents and staff. LPA obtained copies of staff schedule and resident roster. Regarding the allegations facility does not have adequate staffing and facility does not provide adequate hygiene supplies the investigation revealed the following:

The facility is licensed for 98 residents and currently has a census of 18 residents in assisted living and 16 residents in memory care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
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 2
Control Number 22-AS-20250313151337
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: 03/21/2025
NARRATIVE
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Per interview with Executive Director Yaylene Mazariegos there is 1 LVN available Monday - Friday, 1 med-tech on every shift, 1 caregiver for assisted living and 2 caregivers for memory care for AM and PM shifts. Overnight staff is 1 med-tech and 1 caregiver. ED also stated all staff are trained to provide care to residents. Interviews with 2 out of 2 staff stated they are able to assist residents with activities of daily living with the current staffing ratios. Per interviews with 2 out of 2 residents they indicated staff is responsive and assists them as needed. ED stated there is a resident in Memory Care that will wander into other residents rooms and staff will redirect. ED stated most Assisted Living residents are ambulatory and can ask for assistance. LPA Mendivil observed staff responding to pendant calls during the visit.

Interviews with 2 out of 2 residents stated they have not had any issues with hygiene supplies not being available. Residents stated they can ask for hygiene items and the facility will provide them. Per interview with ED, ED stated all except 3 residents in memory care under incontinent care. ED stated the facility provides wipes, briefs and incontinent pads if a resident is under the incontinent care program. ED stated if a resident is not under the incontinent care plan then the resident or resident's family is to provide briefs and wipes. ED stated if a resident that is not under incontinent care plan and runs out of supplies the facility will provide supplies as needed. LPA Mendivil observed a closet with extra supplies ready and available to all staff.

Therefore based on the preponderance of evidence through interviews and observations the allegations that Facility does not have adequate staffing and Facility does not provide adequate hygiene supplies are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint.

No deficiencies cited.

An exit interview was conducted and a copy of this report this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2