331800055-3-20-2023-18-AS-JDHS-CSZW3W-20230621165637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 03/20/2023
Date Signed: 03/20/2023 03:10:17 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, 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
03/30/2020 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200330083408

FACILITY NAME:	PACIFICA SENIOR LIVING HEMET		FACILITY NUMBER:	331800055
ADMINISTRATOR:	MONYA HENRY		FACILITY TYPE:	740
ADDRESS:	1177 S PALM AVE		TELEPHONE:	(951) 216-3932
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	110	CENSUS: 83	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	BUSINESS OFFICE MANAGER, DEIDRE BARRIGER.		TIME COMPLETED:	03:18 PM

ALLEGATION(S):

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Staff providing care to residents are sick.
Unsanitary food service.
Staff failing to adequately clean/disinfect resident rooms.
Facility is not supplying residents with hygiene/sanitation materials.

INVESTIGATION FINDINGS:

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On March 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived unannounced in order to deliver the findings on the listed allegations. LPA Mixson met with Business Office Manager, introduced self and stated the purpose of the visit.

On March 30, 2020, Community Care Licensing (CCL), received information regarding the listed allegations. Information obtained revealed facility has a mitigation plan on file. LPA Mixson attempted to conducted interviews, due to staff failure to return calls and/or to answer calls when LPA Mixson attempted to call, there was not sufficient information obtained to determine if the listed allegations happened. LPA Mixson conducted record reviews in order to obtain additional information in order to conduct an investigation. Information obtained revealed that the facility has a centralized staff check in and temperature check. The facility has a plan in place to limit the spread of COVID 19 and/or other contagious infections. After LPA Mixson's assessment of evidence collected there was not enough evidence to determine that the listed allegations occurred. Therefore, the outcome of the findings is UNSUBSTANTIATED. The outcome of the investigation has been concluded with a finding of UNSUBSTANTIATED. A finding of "Unsubstantiated" means "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.

An exit interview was conducted and a copy of this report was given to Business Office Manger.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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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