336425840-7-12-2023-56-AS-KCLS-CW3NES-20230927102424

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 04/13/2023
Date Signed: 07/12/2023 03:55:18 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
04/05/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230405084549

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: 76	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility staff do not allow resident to leave the facility
Facility staff threatened resident in care

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 residents and staff.

Regarding allegation that facility staff do not allow resident to leave the facility, interview with Executive Director state that the facility is a Memory Care facility. Resident's who reside in the cottage are allowed to roam the gated area freely and any outings outside the facility must be supervised.

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: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20230405084549

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: 04/13/2023

NARRATIVE

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Interview with resident #1 (R1), in question, revealed that R1 understood that the outings are supervised, but R1 wishes to leave the facility without supervision, but instructed that outings without supervision is against facility policy and State regulation.

Regarding allegation that facility staff threatened resident in care, resident #1 (R1) in question was interviewed and R1 could not recall that a staff made a threat. Interview with staff #1 (S1), did not conclude that a threat was ever made to R1. R1 stated that the threat was made of potential financial abuse, but could not recall dates, times or persons making such threats.

Based on the information obtained there is not enough evidence that the facility staff do not allow resident to leave the facility and facility staff threatened resident in care . Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Director Tawfik at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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