336425840-9-12-2023-56-AS-KCLS-CVUTNT-20230920145317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 07/28/2022
Date Signed: 09/12/2023 02:55:40 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
06/13/2022 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220613124632

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:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Annette Torres, Resident Care Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are mishandling the residents medications
Staff are unable to administer the residents medications during the evening hours
Resident is causing harm to other residents while in care
Staff does not address a resident's change in medical condition
Staff inappropriately administered medication to a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA met with Annette Torres.

Regarding the allegation that staff are mishandling the resident’s medications, staff interviews and documents reviewed show that staff are properly handling resident's medication and medications are being properly administered. LPA did not observe any medication errors.

Regarding the allegation that staff are unable to administer resident's medications during evening hours, interviews and records review reveal no clients requiring administration of medications after the hour of 2200. Interviews with staff revealed that if one of the residents were prescribed a medication to take during those hours the facility staff would administer as prescribed.

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: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20220613124632

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: 07/28/2022

NARRATIVE

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Regarding the allegation that resident is causing harm to other residents while in care, Staff interviews does not reveal harming of residents to other residents. The facility stated none of the residents complained of being harmed by other residents. LPA observation saw residents in a clam and docile demeanor.

Regarding the allegation that staff does not address a resident's change in medical condition, staff interviews revealed that when or if a resident has a change in condition it is addressed with responsible parties, and the physician when needed. The staff interviewed denied the allegation and there was no evidence to corroborate.

Regarding the allegation that staff inappropriately administered medication to a resident while in care, records reviewed and obtained show that resident #1 (R1) in question, medications are being dispensed as prescribed. LPA did not observe any medication errors.

Based on the information obtained there is not enough evidence that staff are mishandling the residents medications, staff are unable to administer the residents medications during the evening hours, resident is causing harm to other residents while in care, staff does not address a resident's change in medical condition and staff inappropriately administered medication to a resident while in care Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

A copy of this report was signed by LPA Prieto and Annette Torres and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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