336425840-7-11-2023-56-AS-KCLS-CVFT4A-20230907142336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 07/11/2023
Date Signed: 07/11/2023 02:29:08 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
06/02/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230602093630

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: 78	DATE:	07/11/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility did not inform authorized representative(s) about residents change of medical condition.
Facility staff not meeting resident’s needs.
Staff did not safeguard client's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct a complaint investigation regarding the above allegations. LPA Javier met with Executive Director Eva Tawfik and discussed the purpose of the visit. The investigation consisted of direct observations and interviews with staff and witnesses.

Regarding the allegation that facility did not inform authorized representative(s) about residents change of medical condition, no documentation was found to shown that there was an change of condition for former resident #1 (R1) in care. R1 was medically evaluated with no note of a change of condition that would constitute notifying responsible party of a change of condition. Witness #1 (W1) visiting R1 did not observe change of condition while R1 was residing at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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 56-AS-20230602093630

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: 07/11/2023

NARRATIVE

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Regarding the allegation the facility staff not meeting resident’s needs, interview with staff #1 (S1) and Executive Director Tawfik and documentation obtained reveal the R1 was receiving proper care to meet R1's needs.

Regarding the allegation that staff did not safeguard client's personal belongings, LPA obtained documentation listing the client's personal property and medication, given to the responsible party at time of R1's departure from the facility without further incident.

Based on the information obtained there is not enough evidence that facility did not inform authorized representative(s) about residents change of medical condition, facility staff not meeting resident’s needs and staff did not safeguard client's personal belongings Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

A copy of this report was signed by LPA Prieto and Executive Director Tawfik and facility obtained a copy.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC9099 (FAS) - (06/04)

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