331880550-6-28-2023-18-AS-RSTS-CZN4U8-20240119182419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 06/28/2023
Date Signed: 06/28/2023 10:43:11 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
06/20/2023 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230620114548

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:	09:12 AM
MET WITH:	Melissa Polendo, Executive Director		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility did not issue a refund to resident.
Facility did not safeguard resident's personal belongings.

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, and gathered and reviewed pertinent documentation in relation to this investigation.

It was alleged that Resident One (R1) was supposed to receive 80% of the deposit within 30 days of moving out of the facility, but had not. Documents revealed that R1 lived at the facility from April 30, 2023 until May 22, 2023. R1's Power of Attorney (POA) gave notice to the facility that R1 was to be moved on May 18, 2023.

Continued on LIC9099-C.

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)

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Control Number 18-AS-20230620114548

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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When R1 left the facility, there were still personal items in the room such as a hospital bed, and a bedside table; therefore not completely moving from the facility until May 30, 2023. Admission Agreement indicated that "Leaving the community is defined as moving from the Community and removing your furniture and all other personal belongings."

R1's Power of Attorney signed an Admission Agreement stating that it was understood that if notice was given in the first month, that refund compensation would be at 80%. LPA received documentation that the facility provided the 80% refund on June 28, 2023. Per the Admission Agreement, the facility had 30 days to issue the refund. Document, and interview revealed that the refund was issued as agreed upon. Thus this allegation was Unsubstantiated.

It was then alleged that R1's personal belongings were not safeguarded. R1 was alleged to have had their pair of glasses which were found on R1's roommate's bed. R1 was further reported to have been on R1's roommates bed. Staff interview revealed that R1's glasses were reported to have been moved, but not lost. Confidential interview revealed that R1 had all of their belongings when they moved from the facility, and none were claimed damaged, lost or stolen. 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 was discussed with and provided to ED 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)

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