331800055-2-21-2025-18-AS-TDAN-DE7UZM-20250224150146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 02/21/2025
Date Signed: 02/21/2025 10:35:10 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220222133113

FACILITY NAME:	PACIFICA SENIOR LIVING HEMET		FACILITY NUMBER:	331800055
ADMINISTRATOR:	CRISTINA MILLER		FACILITY TYPE:	740
ADDRESS:	1177 S PALM AVE		TELEPHONE:	(951) 923-2844
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	110	CENSUS: 80	DATE:	02/21/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director Barbara Bogoje		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff are not ensuring resident is thoroughly cleaned
Facility staff are not assisting resident with toileting
Resident does not have pendant/call button
Resident is not provided assistance in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation in regards to the allegations noted above. LPA met with Executive Director Barbara Bogoje and explained the purpose of the visit and the elements of the allegation. The allegations were investigated, which consisted of observations, interviews and records review.
On February 22, 2022, Community Care Licensing received a complaint alleging that facility staff are not ensuring resident is thoroughly cleaned, facility staff are not assisting resident with toileting, resident does not have pendant/call button and resident is not provided with assistance in a timely manner. Regarding the allegation of facility staff are not ensuring resident is thoroughly cleaned. It was alleged that Resident #1 (R1) was observed to be covered in feces while at an appointment in or around March 2022. Interview conducted with R1 revealed that R1 believes they are given “the red-carpet treatment” and admitted that there are times when they can be difficult with the staff. R1 further stated that they get angry with staff and tell them to get out of their room, and it does not matter the task that is being completed, they will tell staff to leave, and staff comply. Staff interviews revealed that staff are not always able to finish providing the care

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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 3

Control Number 18-AS-20220222133113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET	FACILITY NUMBER: 331800055
	VISIT DATE: 02/21/2025

NARRATIVE

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that R1 was being provided with because R1 sometimes instructs the staff to get out of the room. Staff do not want to violate R1s personal rights, so they abide by R1’s wishes. LPA conducted a records review of narrative charting for R1 which revealed that on 3/10/22 staff was trying shave R1 when they attempted to bite staff. On 02/17/22 when staff was conducting a check on R1, R1 reportedly told staff to get out and tried to kick and punch the staff. A further review of resident’s shower sheet form dated 2/28/22 revealed that R1 stated that “nobody here knows how to give a shower”. The form also noted that R1 had forgotten that staff already cleaned their head and hair, so staff repeated the task. Per an interview with current Executive Director the residents have a shower schedule and depending on the resident, the days assigned can range from 1-3 times a week and as needed. The staff make charting entries for showers completed, refused and if laundry was needed to be cleaned. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not ensuring resident is thoroughly cleaned is unsubstantiated.

Facility staff are not assisting resident with toileting.

It was alleged that although R1 wears adult briefs, R1 is reported to be able to use the bathroom with staff assistance, as well as communicate the need to use the restroom, but staff do not provide them assistance. Per an interview with R1, R1 stated that there are times when they are being assisted with toileting and getting their adult brief changed and that if they want staff out, they will instruct staff to leave them alone. Per a review of narrative charting dated 02/17/22 R1 is noted as being aggressive with staff when staff was attempting to conduct a check on them. R1 is noted as telling staff to get out and tried to kick and punch the staff. Per an additional review of the end of shift reports from February 2022 it is noted that staff conducted checks as well as provided R1 with toileting assistance. Per interviews conducted with the current executive Director Barbara Bogoje, the residents are checked at beginning of shifts, throughout the shifts and during last rounds. Due to insufficient evidence to corroborate or refute the allegation of facility staff are not assisting resident with toileting is unsubstantiated.

Resident does not have pendant/call button

It was alleged that R1 did not have a pendant/call button. LPA conducted a review of narrative charting which revealed that R1 did not have a pendant from 2/3/22 to 2/10/22. A further records review revealed that R1 noted to have allegedly destroyed (4) pendants, which included R1 putting their pendant inside a cup of water on separate occasions. It was further alleged from a third-party witness the directive was given to not

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220222133113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET	FACILITY NUMBER: 331800055
	VISIT DATE: 02/21/2025

NARRATIVE

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issue R1 another pendant, and to increase the checks on R1. LPA conducted a records review of narrative charting which indicated staff had increased checks on R1 every 30 minutes beginning 02/06/22. Per an interview with R1, R1 admitted to breaking their pendant, and they use the alarm cord in the bathroom or yell when they need assistance. Per an interview with current Executive Director “If a pendant becomes lost or stolen, a replacement is given to the resident, and there is no limit to replacing the pendants”. Based on observations interviews and records review the allegation of resident does not have a pendant/call button is unsubstantiated.

Resident is not provided assistance in a timely manner

It was alleged that R1 is not being provided assistance in a timely manner. Interview R1 revealed that staff have a difficult time understanding them and that frustrates them and R1 will demand staff to leave their room. During LPA interview with R1, R1 was observed to be difficult to understand as they were speaking in a low voice and mumbling. It was further alleged from a third-party witness to not issue R1 another pendant, and to increase the checks on R1. R1 was reported to often yell and scream at staff while demanding they leave them alone. LPA conducted a records review of Narrative charting that revealed staff had increased checks on R1 every 30 minutes, beginning on 02/06/22. Interview with R1 revealed they use the alarm cord in the bathroom or yell when they need assistance. R1 further stated that they are given the “red carpet treatment”. Based on observations, interviews and records review the allegation of resident is not provided assistance in a timely manner is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this, and LIC811-confidential names list was provided to Executive Director Barbara Bogoje .

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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