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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 02/26/2025
Date Signed: 02/26/2025 04:10:31 PM

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
07/22/2022 and conducted by Evaluator Seo Jeon
COMPLAINT CONTROL NUMBER: 18-AS-20220722151836
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 80DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Barbara Bogoje, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained an unstageable pressure injury while in care
Resident sustained injuries resulting in hospitalization due to unwitnessed fall(s) while in care
Staff did not notify responsible party of resident's change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to deliver findings. LPA Seo Jeon met with Barbara Bogoje, Administrator, and explained the purpose of the visit. The following allegations were investigated by the Department, the investigation included interviews and record review.

It was alleged that resident sustained an unstageable pressure injury while in care. On 02/08/2022 Resident#1 (R1) was transported to the hospital and admitted for a fall. Medical records were reviewed. Medical records dated 02/08/2022 do not indicate any pressure injuries noted. Based on facility records, on 02/21/2022, staff called 911 for R1. A review of facility records titled Narrative Charting was completed. The Narrative Charting dated 02/21/2022 indicated R1 was sent out via 911 due to self-harm. While at the hospital, R1 was diagnosed with a pressure injury. A review of medical records dated 02/21/2022 revealed R1 was diagnosed with a wound.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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 6
Control Number 18-AS-20220722151836
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: 02/26/2025
NARRATIVE
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Wound was described as wound location: left trochanter, type of wound: consistent with pressure related injury, stage was listed as unstageable and wound size was listed as 4.2 x 4 cm. The left trochanter is located at the top of the left thighbone, on the outside of the hip. Interviews with staff were conducted and 5 of 6 staff indicated they did not observe any pressure injuries on R1. The sixth staff did not reveal knowledge of any pressure injuries. During staff interviews, 4 of 6 revealed R1 would pick at their skin causing small wounds. Staff would then clean and bandage the wounds. It was not clear during interviews where the wounds were located on R1. Narrative Charting dated 02/19/2022 corroborated staff interviews. The Narrative Charting revealed care staff reported R1 is pinching their skin, causing small wounds, the wounds were cleaned and bandaged. R1 was not able to be interviewed.

Based on interviews and records review the allegation of resident sustained an unstageable pressure injury while in care 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.

It was alleged that resident sustained injuries resulting in hospitalization due lack of care and supervision. R1 moved into the facility on 01/13/2022. R1’s Physicians Report dated 12/17/2021 indicated R1 was ambulatory. The Physician’s Report does not list R1 as a fall risk. R1’s AL Advantage Memory Care Resident Assessment was reviewed. The assessment is neither dated nor does it include R1’s name. However, the assessment was provided by the facility staff as relating to R1. The assessment indicates R1’s level of assistance as R1 was to receive (8) eight status checks per shift. Investigation did not reveal documentation of the eight (8) status checks per shift. Staff interviews revealed R1 was found on the floor. Staff interviews further indicated R1 was transported to the hospital on 02/08/2022 due to the un-witnessed fall. Medical records dated 02/08/2022 revealed R1 was noted with a contusion to the right elbow and the back of the right hand. R1 was discharged back to the facility on 02/09/2022. Narrative Charting dated 02/21/2022, revealed R1 was sent back to the hospital due to self-harm. Medical records dated 02/21/2022 revealed R1 had a chief complaint of agitation. Medical records for the 02/21/2022 hospital visit is where it was revealed an “anticipated” diagnosis of right hip fracture.

Based on interviews and records review the allegation of resident sustained injuries resulting in hospitalization due lack of care and supervision is unsubstantiated. A finding that the complaint is unsubstantiated means
Continued on LIC9099-C...
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
07/22/2022 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220722151836

FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 80DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Barbara Bogoje, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not address resident's change in condition while in care
Staff did not meet the needs of resident in care
INVESTIGATION FINDINGS:
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It was alleged that staff did not address resident's change in condition while in care. On 2/8/2022 R1 was transported to the hospital and admitted for a fall, supportive documents revealed R1 was in their apartment sitting in a chair when they tried getting up and then fell. R1 sustained injuries from their fall, contusion to the right hand and elbow. R1 returned to the facility from the hospital on 2/9/2022, according to records obtained R1s physician report revealed R1 was ambulatory and not listed as a fall risk. There were no new appraisals or assessments completed by the facility staff indicating a change in R1s condition. Discharge orders from the hospital included literature for patient information and understanding your risk for falls.

Based on interviews and records review R1 was not reassessed by the facility staff after experiencing a fall and being hospitalized, therefore the allegation staff did not address resident's change in condition while in care is found to be substantiated.

Continued on LIC9099-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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 6
Control Number 18-AS-20220722151836
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: 02/26/2025
NARRATIVE
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It was alleged that staff did not meet the needs of resident in care. Resident (R1) moved into the facility on 01/14/2022, according to records obtained R1s Physicians report indicated R1 baseline is cognitive impairment, including screaming episodes, confusion, and hallucination. R1s physician report also revealed R1 was ambulatory and not listed as a fall risk. Facility staff made several observations of R1s exhibited behaviors consisting of screaming episodes, displaying confusion, and hallucinating. In addition, staff observed R1 throw themselves out of their wheelchair on a regular basis. On 2/8/2022 R1 was transported to the hospital and admitted for a fall, supportive documents revealed R1 was in their apartment sitting in a chair when they tried getting up and then fell. R1 sustained injuries from their fall, contusion to the right hand and elbow. R1 returned to the facility from the hospital on 2/9/2022, there were no new appraisals or assessments completed by the facility staff indicating a change in R1s condition. According to information obtained through staff interviews, the facility did not provide one-on-one service to any residents. Additionally, the facility had three (3) caregivers per shift for twenty-five (25) residents. The facility also had one (1) medical technician, who would fulfill caregiver duties after passing medications. Information obtained through interviews revealed the med-tech would move the resident closer to them (med-tech) whenever the med-tech had to attend to other residents who required their assistance.

Based on interviews and records review R1 was not reassessed by the facility staff after experiencing a fall and being hospitalized, therefore the allegation staff did not meet the needs of resident in care is found to be substantiated.

The preponderance of the evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20220722151836
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
87463
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Reappraisals: The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented. This was not met by:
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Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved.
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Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 was hospitalized due to a fall, after being discharged from the hospital R1 was not reassessed to determine level of care for R1. This was an immediate safety risk to R1.
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Type B
03/07/2025
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and ... responsible person ...This was not met by:
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Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved. A new procedure will be created for a updated care plan for residents.
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Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 exhibited throwing themselves out of their wheelchair on a regular basis. R1 was hospitalized due to a fall. This was an immediate safety risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20220722151836
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: 02/26/2025
NARRATIVE
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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.

It was alleged that staff did not notify responsible party of resident's change in condition. Information obtained through interviews revealed upon R1s admission to the facility, R1 was observed in their wheelchair covered with a blanket and a lap belt on them to secure them in the wheelchair to prevent them from falling. After R1’s admission, the facility staff removed the lap belt due to the lap belt being a form of restraint. According to staff’s observations R1 would then proceed to throw themselves out of the chair on a regular basis. R1 was provided with a recliner by R1s daughter however this was identified as another form of restraint. In addition, R1 began to exhibit behaviors, picking at their skin on a regular. Staff would treat R1s wound by cleaning and bandaging R1 each time R1 would pick at their skin. Evidence gathered during this investigation confirms the facility staff and R1s power of attorney (POA) were in constant communication via in-person visits, phone calls, and or text messages regarding R1s activities of daily living (ADL’s).

Based on interviews and records review the allegation of staff did not notify responsible party of resident's change in condition 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.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6