336425840-1-29-2025-18-AS-EMAN-DE8MZN-20250225090324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:47:33 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
08/03/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210803122229

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:	01/29/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director Eva Tawfik		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident died due to staff neglect.
Resident developed multiple pressure injuries due to neglect.
Facility failed to seek timely medical care for resident.
Facility did not meet resident's needs.
Facility staff did not follow sanitary precautions during care of resident.

INVESTIGATION FINDINGS:

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

On 01/29/2025 at 01:30 PM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the above allegations. LPA Brown identified herself and discussed the purpose of the visit with Executive Director (ED) Eva Tawfik.

The investigation of the first allegation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates resident died due to staff neglect. The Department staff interviewed six (6) of six (6) staffs and six (6) of six (6) staffs indicated that when Resident #1 (R1) was placed in Pacifica Senior Living of Riverside on 05/21/2021, R1 had a documented multiple health diseases and non-ambulatory. Interviews with six (6) of six (6) staffs revealed that R1 was receiving home health with nurse visits three (3) times per week. Staff #3 (S3) and Staff #5 (S5) reported to Department staff that Staff #6 (S6) contacted home health on 07/08/2021 as R1's catheter became dislodged, and a nurse was dispatched to the facility, *** Continuation in LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

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 4

Control Number 18-AS-20210803122229

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: 01/29/2025

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

but the home health nurse was unsuccessful to re-insert the catheter and they called for medical emergency. S3 and S5 added that R1 was transported to the hospital. Department staff reviewed R1's medical records and it indicated that R1 was admitted to the hospital with multiple medical issues. Moreover, R1's medical records revealed that R1 passed away on 07/14/2021 at the hospital with the primary cause of death listed.

The second allegation indicates resident developed multiple pressure injuries due to neglect. During the Department investigation, six (6) of six (6) staffs interviewed indicated that R1 was placed in Pacifica Senior Living of Riverside on 05/21/2021 and R1 had documented multiple medical issues and non-ambulatory. Interviews with six (6) of six (6) staffs revealed that R1 was receiving home health with nurse visits three (3) times per week. Six (6) of six staffs interviewed reported that R1 was a two person assist and they are using Hoyer lift to transfer R1 from R1's bed to R1's wheelchair. Interviews with six (6) of six (6) staffs indicated that caregiver staffs at the facility are turning or repositioning R1 every two (2) hours. Medical records indicated that a meeting was conducted on 06/25/2021 and meeting notes documented that R1 was doing well, and wounds are healing slowly and R1 would be transferred to home health. In addition, Department staff noted that the pictures taken by the hospital of R1's wounds on or about 07/08/2021 showed that some wounds are improving while others were not. Department staff added that R1's medical records indicated that the wounds on R1's legs were diabetic ulcers. Due to insufficient evidence, the Department was not able to corroborate the allegation that resident developed multiple pressure injuries due to neglect.

The third allegation indicates facility failed to seek timely medical care for resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are always seeking timely medical care for them if they are sick and not feeling well. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are always seeking timely medical care for their residents. Five (5) of five staffs interviewed reported that there's no incident that happened at the facility that they failed to seek timely medical care for a resident. Five (5) of five (5) staffs interviewed revealed that there's no incident that they did not seek timely medical care for R1 as any changes they observed on R1 or change of condition were all reported to R1's home health nurse and home health nurse was immediately dispatch to the facility after they notified them. ***Continuation in LIC9099C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20210803122229

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: 01/29/2025

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

The fourth allegation indicates facility did not meet resident's needs. Interviews with three (3) of three (3) residents indicated that staffs at the facility are meeting their needs. Three (3) of three (3) residents interviewed reported that staffs at the facility are checking on them four (4) to five (5) times in a day, providing them a shower two (2) or three (3) times in a week, brushing their teeth and staffs are making sure that they are wearing clean clothes. Three (3) of three (3) residents interviewed indicated that staffs at the facility are always ready to assist them if they need help. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are providing care and supervision to all their residents to ensure that they are meeting their needs. Five (5) of five (5) staffs interviewed reported that there's no incident that happened at the facility that they did not meet R1's needs. Five (5) of five (5) staffs interviewed revealed that they are always checking on all their residents every two (2) hours, more often if needed to ensure that they are providing appropriate care and supervision to their residents and to meet their needs. During the facility visit on 01/24/2025, LPA Brown observed staffs at the facility providing care and supervision to their residents.

The fifth allegation indicates facility staff did not follow sanitary precautions during care of resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are always following the sanitary precautions when they are assisting them and providing care. Three (3) of three (3) residents interviewed reported that staffs at the facility are always wearing gloves when they are assisting them and will take off the gloves when they are leaving their room. Three (3) of three (3) residents interviewed stated that staffs at the facility are following sanitary precautions when they are providing care. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they always follow the sanitary precautions when they are providing care to their residents. Five (5) of five (5) staffs interviewed reported that when they are providing care to their residents, they are using new sets of gloves and they make sure that when they are leaving the residents room, they are taking off the gloves, throw it in the trash bin and sanitized their hands. In addition, five (5) of five (5) staffs interviewed revealed that they were provided training at the facility on sanitary precautions and infection control when they are providing care to their residents. Five (5) of five (5) staffs interviewed stated that there's no incident that happened at the facility that they did not follow the sanitary precautions when they are providing care to R1. During the facility visit on 01/24/2025, LPA Brown observed staffs at the facility are following sanitary precautions when they are providing care to the residents. ***Continuation in LIC9099C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20210803122229

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: 01/29/2025

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

Therefore, based on the evidence obtained during the Department staff and LPA Brown's investigation, there is insufficient evidence to prove that resident died due to staff neglect (Allegation #1), resident developed multiple pressure injuries due to neglect (Allegation #2), facility failed to seek timely medical care for resident (Allegation #3), facility did not meet resident's needs (Allegation #4), and facility staff did not follow sanitary precautions during care of resident (Allegation #5) are unsubstantiated at this time. Although the allegations of resident died due to staff neglect, resident developed multiple pressure injuries due to neglect, facility failed to seek timely medical care for resident, facility did not meet resident's needs, and facility staff did not follow sanitary precautions during care of resident may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report (LIC9099) was discussed and provided to Executive Director Eva Tawfik.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4