336425840-1-6-2025-56-AS-KCLS-DE6LNT-20250223075453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 05/01/2024
Date Signed: 01/06/2025 02:39:48 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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2024 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240430155237

FACILITY NAME:	PACIFICA SENIOR LIVING RIVERSIDE		FACILITY NUMBER:	336425840
ADMINISTRATOR:	EVA TAWFIK		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	110	CENSUS:	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent resident from harming another resident in care
Staff did not provide adequate supervision to resident in care resulting in a fall

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to initiate a complaint investigation regarding the mentioned allegations. LPA Prieto met with Executive Director Eva Tawfik to discuss the complaint elements. The investigation included interviews with staff and residents, observations, and a review of relevant documents.Regarding the allegation that staff did not prevent a resident from harming another resident in care, LPA Prieto interviewed residents R1 and R2, who were involved in the incident. Both residents stated that they do not recall any incident or altercation occurring and did not express any concerns about a lack of staff or care.LPA Prieto also interviewed staff member S1, who was present during the altercation. S1 observed the incident but was unable to prevent it as it occurred quickly. S1 took the appropriate steps by calling other staff members and ensuring that R1 received medical attention by sending them to a medical facility. ***continued on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 56-AS-20240430155237

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 05/01/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Prieto interviewed S2, who was present at the time of the altercation. S2 stated that there was proper supervision in accordance with regulations and that the appropriate follow-up steps were taken after the incident. LPA Prieto also interviewed S3, who works with R1, and confirmed that staffing was adequate per regulations and that there had been no previous instances of aggression from R1 or R2.

Regarding the allegation that staff did not provide adequate supervision, resulting in a fall, LPA Prieto interviewed S1, S2, and S3, all of whom were present at the time of the altercation. Administrator Tawfik provided the names of S4 and S5, who were working in the cottages where the altercation occurred and met the required supervision standards according to regulations.

Based on the information obtained, there is insufficient evidence to support the allegations that staff failed to prevent a resident from harming another resident and that staff did not provide adequate supervision resulting in a fall. Therefore, these allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Tawfik, and a copy was left with the facility.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2