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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 06/30/2025
Date Signed: 06/30/2025 10:43:26 AM

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
02/22/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230222155535
FACILITY NAME:PACIFICA SENIOR LIVING PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR:ROBERT STANSBURYFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:95CENSUS: 72DATE:
06/30/2025
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Tammy Eddy, Executive Director TIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining broken femur.
Staff did not seek medical treatment for resident.
Licensee did not notify POA of resident fall.
INVESTIGATION FINDINGS:
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On 06/30/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations noted above. LPA met with Tammy Eddy, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, which consisted of interviews and records review.

It was alleged staff neglect resulted in Resident 1 (R1) sustaining a broken femur. A review of R1’s Resident Assessment dated 09/30/2022 revealed R1 is a full assist with daily living, unable to walk, and uses a wheelchair. A review of R1’s Needs and Services Plan dated 06/28/2022, R1 is noted to be a fall risk, and a 2 person assist. Interviews revealed on 01/28/2023, R1 sustained an unwitnessed fall. R1 was observed on the floor in their room yelling in pain. Staff interviews further revealed, multiple staff responded to R1s room as they had heard someone from the room scream/yell in pain. Staff observed R1’s hospital bed to be in the high position with the bed rail in an upward position, used to keep R1 from falling out of bed, but was observed to be in the lowered position.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
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 5
Control Number 18-AS-20230222155535
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: 06/30/2025
NARRATIVE
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Staff interviews conducted, confirmed the bed rails should have been in the up position and the hospital bed was observed to be in the lowered position. Information obtained from staff interviews revealed, if R1s bed were not left in the down position, R1 would not have fallen from their bed. In addition, the bed rails being put in the “up” position would prevent R1 from falling out of the bed, being that R1 would have behaviors that being that included moving around in the bed. A review of medical records dated 02/02/2023 revealed that R1 was diagnosed with an acute left femoral sub capital fracture with superior lateral displacement and varus angulation. R1 was required to have surgery after being admitted to the hospital. Therefore, the allegation of staff neglect resulted in resident sustaining broken femur is substantiated.

Staff did not seek medical treatment for resident.

According to staff interviews information revealed on 1/28/2023 at around 2:30pm R1 sustained an unwitnessed fall, this was confirmed by staff who responded to R1s room as they had heard someone from the room scream/yell in pain, upon arrival R1 was the only person in the room. A record review was conducted of the End of Shift Reports, these are reports completed by facility staff at the end of their shifts. The reports revealed the following: a written entry note stating “at the beginning of shift med tech received a call from Resident Assistant in Elm unit, R1 was on floor near bed, the med-tech conducted an assessment and indicated there were no visible cuts or bruising, and R1 was not complaining of pain. Additional information from the End of Shift Reports revealed following: dated 01/29/2023, note R1 seemed agitated and was kicking and yelling; on 01/30/2023, R1 was in pain on their left leg when staff attempted to turn R1; on 01/31/2023, R1 was in a lot of pain when attempts were made to turn and change R1, and hospice was notified.

A record review of hospice records was conducted and revealed the hospice agency was notified of R’s fall on 02/01/2023 by a non-staff individual. A review of an Unusual Incident Report dated 01/28/2023 revealed during safety checks R1 was found in their room on the floor near the bed and R1 denied any pain at the time. The Unusual Incident Report also indicated there was no apparent injury. A visit from R1s hospice agency was conducted and a request was made to the hospice agency to get x-rays completed. X-ray results revealed a left hip fracture, resulting in R1 being sent out for further medical evaluation on 02/02/23, five (5) days after the injury/incident occurred. Therefore, the allegation of staff did not seek medical treatment for resident is substantiated.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230222155535
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: 06/30/2025
NARRATIVE
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Licensee did not notify POA of resident fall.

On 1/28/23 during safety checks R1 was found on the floor. It was determined that R1 had an unwitnessed fall. Per a records review conducted an unusual Incident/Injury report dated 1/28/23 sustained documenting that R1 suffered a fall on 1/28/2023, noting that R1s Primary Care Physician (PCP) and Power of Attorney (POA) were notified. Per a further records review revealed that there was an addition Unusual Incident/Injury report dated 2/2/23 stating that CCL, was informed of the incident on 2/8/23, Primary Care Physician 2/2/23, Placement agency (hospice) on 2/2/23 and R1s responsible party on 2/2/23. Per an interview with previous Residential Services Director Melissa Polendo who allegedly informed R1s POA and PCP of the incident, however Melissa stated that she was not the one that directly notified R1s POA and PCP, but the Medication Technician/Staff #1 (S1) was the one that did.

Per an interview with S1 whom stated they informed their supervisors via text message. A further records review revealed that S1 was written up for not following up to ensure the supervisors were properly notified of the incident. Per an interview with R1s POA denied being contacted by facility staff regarding R1s fall on 1/28/23. The department is noted to have been notified of the incident on 2/8/23 however, there was no confirmation of the report being submitted/received. The Unusual Incident/Injury report dated 1/28/23 and 2/8/23 were not signed by the Executive Director nor was there a fax confirmation accompanying the reports. Based on interviews and records review the allegation of licensee did not notify POA of resident fall is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $500 is being assessed. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted and a copy of this report, 9099C, 9099D, appeal rights, LIC421IM, and LIC811-Confidential names list was reviewed and provided to Tammy Eddy, Executive Director.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230222155535
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: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2025
Section Cited
CCR
87464(1)(c)
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Basic Services (1)Care and supervision defined in 87101(c)... (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident' s physical health, mental health
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The Licensee agrees to conduct an in-service on the importance of following resident care plan. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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safety, or welfare would be endangered. Assistance medications, money mgmt, or personal care. This requirement is not met as evidenced by: Facility staff did not ensure bed rails were in the upright position which caused an immediate health safety and personal rights risk to persons in care.
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Type A
07/01/2025
Section Cited
CCR
87468.1
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87468.1- 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: (16) To receive or reject medical care or other services. This requirement has not been met as evidenced by:
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The Licensee agrees to conduct a review of resident fall risk procedures. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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 the Licensee did not seek timely medical attention for R1. This is a immediate health safety and personal risk to person's in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230222155535
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: 06/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2025
Section Cited
CCR
87211(a)(1)
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Reporting requirements : (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident
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The Licensee agrees to conduct an in-service on the importance of incident reporting and follow with RSD to ensure timely reporting to all applicable parties.
Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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7 days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: the licensee did not notify R1s responsible party of the incident, which posed a potential health, safety and personal rights risk to person's in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5