331880550-6-28-2023-18-AS-JESL-CU9ME2-20230731093201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:03:40 PM

Substantiated

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
06/23/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230623122540

FACILITY NAME:	PACIFICA SENIOR LIVING PALM SPRINGS		FACILITY NUMBER:	331880550
ADMINISTRATOR:	MELISSA POLENDO		FACILITY TYPE:	740
ADDRESS:	1780 E BARISTO RD		TELEPHONE:	(760) 322-3444
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	95	CENSUS: 66	DATE:	06/28/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Melissa Polendo, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff did not ensure the shower/tub was kept in a state of repair
Staff did not ensure resident's shower seat was fixed properly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to initiate an investigation into the allegations listed above. LPA met with Executive Director Melissa Polendo and explained the purpose of the visit. LPA interviewed staff, residents, and made observations.

It was alleged there has been mold "or something" on the bottom of Resident One (R1's) tub where the calking is. The facility put a substance over it to repair it; however, it continues to return. Further, it was alleged that the shower seat is loose and; although the facility is aware, nothing is being done about it.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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 5

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
06/23/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230623122540

FACILITY NAME:	PACIFICA SENIOR LIVING PALM SPRINGS		FACILITY NUMBER:	331880550
ADMINISTRATOR:	MELISSA POLENDO		FACILITY TYPE:	740
ADDRESS:	1780 E BARISTO RD		TELEPHONE:	(760) 322-3444
CITY:	PALM SPRINGS	STATE: CA	ZIP CODE:	92262
CAPACITY:	95	CENSUS: 66	DATE:	06/28/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Melissa Polendo, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Food is not of good quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to initiate an investigation into the allegations listed above. LPA met with Executive Director Melissa Polendo and explained the purpose of the visit. LPA interviewed staff, residents, and made observations.

It was alleged that the food just does not "look good". It was reported to be cold and the facility doesn't change the menu, and that the food does not have variety. LPA conducted interviews with residents, and reviewed/obtained documentation. At the conclusion of the interviews conducted with residents, residents stated that although food temperature was disputed, the majority of interviews concluded that the food is of right temperature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20230623122540

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: 06/28/2023

NARRATIVE

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Additionally, residents concluded that if an item is not wanted on the menu, an alternative selection is always available. Documentation received from the facility paralleled the resident interviews. Thus, this allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report and a copy of the LIC9099-C was provided to Executive Director Melissa Polendo.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20230623122540

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: 06/28/2023

NARRATIVE

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LPA interviewed residents and made observations of the reported living environment and found that there was a substance black in color on top of the calking, as well as cracking in the tub, and noted the shower seat being loose. Interview with staff revealed that R1 advised of the situation on April 11, 2023, and staff was given a quote by the vendor for repair. Staff interview further revealed that on April 28, 2023, R1 followed up with staff regarding the repair of the seat and condition of the shower. As of June 28, 2023, staff is waiting on other vendors to rectify the damage. Based on staff interview, and observations made, LPA found that both allegations were Substantiated. The facility was cited per Title 22.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was provided along with copies of the LIC9099-C, LIC9099-D, and Appeal Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 18-AS-20230623122540

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/05/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to draft a repair plan for the damaged unit by 7/5/2023. Further, in-service training will be conducted on the cited reguation, and also due 7/5/23.
	8 9 10 11 12 13 14	Based on interview, and LPA observation, R1 was not accorded a safe environment by the shower seat being loose. This is a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 07/05/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to draft a repair plan for the damaged unit by 7/5/2023. Further, in-service training will be conducted on the cited reguation, and also due 7/5/23.
	8 9 10 11 12 13 14	Based on interview, and LPA observation, R1 was not accorded an environment that was not is disrepair. This is a potential personal rights risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

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