331800055-4-7-2025-18-AS-RORN-DFJMDG-20250408093106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:45:04 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
12/21/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 18-AS-20221221141339

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: 84	DATE:	04/07/2025
		UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Barbara Bagoje - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained injuries due to a fall
Staff leave residents unattended in dirty diapers for extended periods of time
Staff mismanage residents' medication
Staff failed to treat residents with dignity and respect
Staff do not ensure that residents are hydrated
Staff handle residents in a rough manner
Facility is unkempt

INVESTIGATION FINDINGS:

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*This report supersedes report dated 4/5/25 to correct documents information and dates for R2's records on LIC 9099C.*
On 4/5/25 Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Nidia Chavez Activities and explained the reason for the visit.

The investigation consisted of the following: On 3/26/25 LPA Flores requested a copy of staff/resident roster over the phone. On 4/2/25 LPA requested documents for three residents over the phone. On 4/4/25 LPA conducted a visit at the facility interviewed administrator, 5 staff, 8 residents, and 1 staff over the phone. LPA toured the facility with Annette Harris concierge and observed 7 random resident room and common areas. LPA reviewed files for Resident #1-2(R1-R2) and requested copies of Physician’s Report, Identification and Emergency Information sheet, Needs and Care plan, medical records.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221221141339

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: 04/07/2025

NARRATIVE

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LPA requested copies of incident reports, and medication destruction logs for the past three months, medication training for 2 medication technicians(Med-Tech), personal rights training, training on dementia care and activities of daily living for 2 caregivers. LPA reviewed medication for 5 residents. On 4/5/25 LPA delivered findings.

The investigation revealed the following: Regarding allegations: Resident sustained injuries due to a fall. It is alleged around December 2022, R2 sustained an unwitnessed fall which left R2 with bruises and lacerations. Interviews conducted with residents revealed 4 out of 8 residents were unable to answer due to cognitive skills. 2 out of 8 residents stated to have fallen and staff provided assistance right away and 2 out of 8 residents stated to not fallen while in care but are certain staff will assist them right away if it happens. Interviews with staff revealed facility has a protocol for residents falls. Per staff if a resident falls Med-Techs are called. Med-techs evaluate the resident and if the resident is laying on their back or hit their head they are send out to the hospital for further evaluation. Staff stated that they have staff checking on residents and are aware of residents that need assistance. Those residents that need additional assistance are maintain within supervision range. Documents review revealed the following, per physician’s report dated:12/16/21, R2 is non-ambulatory and there were no notes of being a risk fall. Per needs and care plan dated 12/22/21 R2 requires a 2 person assist escort and total assistance with transferring. Medical records reviewed revealed R2 was seen on 10/13/22 due to a hematoma. On 11/7/22 R2 was seen at the hospital due to a mechanical fall. On 12/13/22 R2 was seen by a physician due to a fall. R2 was not under hospice or home health care. Medical record dated 10/13/22 notes R2 was seen for a hematoma. However, it does not note whether the reason was a fall. There were no incident reports to review for the falls above. Therefore, although R2 did sustained 2 falls per medical records and a hematoma is unclear whether those were due to lack of supervision. Therefore, the allegation is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff leave residents unattended in dirty diapers for extended periods of time. It is alleged residents are left unchanged for an extended period of time. Interviews conducted with residents revealed 3 out of 8 residents do not need assistance with incontinence care and stated staff assist with care as needed. 3 out of 8 residents were unable to answer due to cognitive skills and 2 out of 8 residents stated facility staff assist residents with going to the bathroom and changing as needed.
(CONTINUED ON LIC 9099C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20221221141339

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: 04/07/2025

NARRATIVE

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Interviews with staff revealed 4 out of 7 staff stated caregivers who assist residents with incontinence care check residents every two to three hours and check residents as needed. 2 out of 7 staff were not aware of concerns with incontinence care. 1 out of 7 staff stated that a resident was found wet with a full pull up in the morning recent. The incident was report it to management. Administrator stated staff was given a written warning a copy of warning was reviewed.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff mismanage resident’s medication. It is alleged staff mix up the residents’ medication and the facility keep the deceased residents’ medication. Interviews with residents revealed 5 out of 8 residents do not have concerns regarding medication management. 3 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed 4 out of 7 staff interview stated medications have not been mixed and medications are properly after a resident leaves or passes away. Medication is destroyed by placing them in a destruction container with a witness, staff destroying medication signs destruction medication log, and the destroyed medication in secure container are picked by contractor at least every three months. Medication review did not reveal errors or mismanagement of current residents’ medications. LPA observed the medication destruction container and did not observe old medications stored. LPA reviewed medication destruction logs for 7 residents were reviewed. Last medication training was provided on 4/3/25.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff failed to treat residents with dignity and respect and Staff handle residents in a rough manner. It is alleged a resident was treated with force when the resident refused to shower. Interviews with residents revealed 6 out of 8 residents stated staff treat them with respect when providing care. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed staff have not mistreated or observed staff mistreating residents in care. Administrator and staff were unable to identify the resident in question. Administrator searched through stored records. However, there were no resident found with the name provided or incident described. Last Resident Rights training was provided to staff on 12/17/24.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.(CONT.LIC9099C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20221221141339

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: 04/07/2025

NARRATIVE

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Regarding allegation: Staff do not ensure residents are hydrated. It is alleged most of the residents are dehydrated as the staff do not make sure to give the residents enough drinking water. Interviews conducted with residents revealed 6 out of 8 residents stated facility provides proper care. 2 out of 8 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff provide care with all activities of daily living and residents are encouraged to drink water throughout the day. During facility’s tour LPA observed large water dispensers supplied with cups in each dining area and in the admission building. Staff were last provided training on dementia care on 1/21/25.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Facility is unkempt. It is alleged facility is dirty and sometimes the residents have feces on their beds. Interviews conducted with residents revealed 6 out of 8 residents interviewed stated the facility its clean and their bedding is changed often. 2 out of 8 residents were unable to answer due to cognitive skills. Interviews with staff revealed facility is maintained clean and the bedding is changed at least every three days or as needed. Per Annette Harris concierge residents provide their own bedding supplies. During facility’s tour LPA observed the facility’s common areas were clean and each bed observed had clean sheets and bedding supplies. LPA observed memory care cottages had additional bedding supplies in the laundry room.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Barbara Borgoje Administrator and a copy of this report was email for signature.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC9099 (FAS) - (06/04)

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