<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:57:11 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
04/18/2023 and conducted by Evaluator Patricia Velazquez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230418134043
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: 41DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Stacie Anderson - Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident had a comfortable environment
Resident's food is served cold
Staff did not notify responsible party of incident
Resident received unauthorized services
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation. LPA Velazquez 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 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, Identification and Emergency Information, Preplacement Appraisal Information, Admission Orders, Needs and Services Plan, Physician's Reports, Facility Internal Incident Report, Fax communication from the facility to Bi Rite Pharmacy, Medication Administration Records, a copy of text communication between Resident (R) #1's family member and the facility regarding a diagnostic study to be performed on R1, Copies of invoices from Splash Plumbing dated March 6, 2023 and March 11, 2023, and a Residence and Care Agreement.
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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 5
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: 06/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Staff did not ensure that resident had a comfortable environment, 9 of 9 individuals interviewed provided conflicting statements and could not corroborate the allegation. 6 of 9 individuals interviewed stated the temperature in their room was satisfactory and had no complaints about the room temperature. On today's visit LPA Velazquez tested the ambient temperature in resident rooms and it measured from 75 degrees Fahrenheit - 79 degrees Fahrenheit which is within regulatory requirements. Per ED Anderson, some residents ask that the thermostat be set at 90 degrees Fahrenheit which would exceed regulatory requirements.

Regarding the allegation: Resident's food is served cold, 9 of 9 individuals interviewed provided conflicting statements and could not corroborate the allegation. 8 of 9 individuals interviewed stated their food was served hot and had no complaints about the temperature of the food.

Regarding the allegation: Staff did not notify responsible party of incident, 9 of 9 individuals interviewed provided conflicting statements and could not corroborate the allegation. Per the facility's Internal Incident Report, R1's family member was notified via phone with a voicemail message left at 6:10 PM on April 4, 2023. 3 of 3 individuals stated R1's family member was notified when R1 was sent out to the hospital.

Regarding the allegation: Resident received unauthorized services, 9 of 9 individuals interviewed provided conflicting statements and could not corroborate the allegation. 2 of 3 individuals stated R1's family member was aware of the diagnostic test R1 received as it was required for admission into the facility.

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: Staff did not ensure that resident had a comfortable environment, Resident's food is served cold, Staff did not notify responsible party of incident, and Resident received unauthorized services are deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Stacie Anderson and a copy of this report 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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 COASTFACILITY NUMBER:
306005272
ADMINISTRATOR:STACIE ANDERSONFACILITY TYPE:
740
ADDRESS:2619 ORANGE AVETELEPHONE:
(949) 515-0121
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:98CENSUS: 41DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Stacie Anderson - Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's toilet is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Patricia Velazquez conducted a subsequent complaint visit to deliver the findings of the investigation. LPA Velazquez 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 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, Identification and Emergency Information, Preplacement Appraisal Information, Admission Orders, Needs and Services Plan, Physician's Reports, Facility Internal Incident Report, Fax communication from the facility to Bi Rite Pharmacy, Medication Administration Records, a copy of text communication between Resident (R) #1's family member and the facility regarding a diagnostic study to be performed on R1, Copies of invoices from Splash Plumbing dated March 6, 2023 and March 11, 2023, and a Residence and Care Agreement.
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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 5
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: 06/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation: Resident's toilet is in disrepair, 9 of 9 individuals interviewed provided conflicting statements and could not corroborate the allegation. ED Anderson stated one resident's toilet became clogged and caused leaking. ED Anderson contacted Splash Plumbing who came and addressed the plumbing issue. The records reviewed included 2 Splash Plumbing invoices dated March 6, 2023 and March 11, 2023 for the plumbing job performed by the company. The invoices further document "removed large amount of wipes." There have been no further plumbing issues at the facility since the issue was addressed in March 2023.


Based on the observations made, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Resident's toilet is in disrepair, is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. The citation was cleared at the time of this visit as the plumbing issue was addressed and corrected back in March 2023.

An exit interview was conducted with Executive Director Stacie Anderson and a copy of this report along with the appeal rights were provided at the time of this visit. A copy of the clearance letter was also 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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2023
Section Cited
CCR
87303(e)(6)
1
2
3
4
5
6
7
Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement
1
2
3
4
5
6
7
The citation was cleared at the time of this visit as the issue was previously addressed.
8
9
10
11
12
13
14
was not met as evidenced by: based on record review and interview the Licensee did not ensure the toilets were properly maintained. This poses a potential risk to the health & safety of residents in care.
8
9
10
11
12
13
14
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 SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5