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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 04/25/2025
Date Signed: 04/25/2025 09:58:03 AM

Unfounded


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
07/25/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230725110331
FACILITY NAME:PACIFICA SENIOR LIVING PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR:MELISSA POLENDOFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:95CENSUS: 74DATE:
04/25/2025
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Tammy Eddy, Executive Director TIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining an unexplained injury while in care.
INVESTIGATION FINDINGS:
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On 04/25/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation noted above. LPA met with Tammy Eddy and explained the purpose of the visit and the elements of the allegation.

The allegation was investigated, which consisted of observations, interviews and records review. On 07/25/23 Community Care Licensing received a complaint alleging staff neglect resulted in a resident sustaining an unexplained injury while in care. It was alleged that Resident #1 (R1) was observed to have a possible left femur fracture, as there was a bump on their left leg with swelling as well as a deformity to R1s left leg (hip). Information obtained from an interview conducted with facility Corporate Director of Dementia Services Melissa Polendo, denied R1 sustained any falls while at the facility. Additional staff interviews revealed R1 did not have wandering behaviors and would always ask for assistance. A records review of R1s narrative charting, revealed on 07/24/23 while having their brief changed, R1 was observed to have a bump on their left hip and was sent out for a medical evaluation.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 2
Control Number 18-AS-20230725110331
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 PALM SPRINGS
FACILITY NUMBER: 331880550
VISIT DATE: 04/25/2025
NARRATIVE
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R1 was admitted to a local hospital with hip pain. After further assessment the diagnosis given was mechanical function also known as “painful ortho hardware failure” due to a previous procedure. The mechanical function is not associated with a fall as it was also believed that was how R1 sustained the injury.

Based on observations, interviews and records review the allegation of staff neglect resulted in a resident sustaining an unexplained injury while in care is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report, 9099C, LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2