336425840-4-4-2025-56-AS-KCLS-DFHVTM-20250407164323

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 02/19/2025
Date Signed: 04/04/2025 02:37:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/07/2022 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20221107142123

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: 75	DATE:	02/19/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not follow resident's care plan resulting in resident sustaining a pressure injury
Staff handled resident in a rough manner
Staff are not properly mitigating the scabies outbreak at the facility
Facility's laundry machine is in disrepair
Staff did not inform resident's authorized representative of resident's incident

INVESTIGATION FINDINGS:

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****This is an amendment ****

On 4/2/2025 at 1:00 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to the Executive Director Eva Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation.
The investigation was conducted by LPA Serrano. The allegations indicate:

#1 Staff did not follow resident's care plan resulting in resident sustaining a pressure injury – Based on staff interview, and record review, LPA is unable to identify resident #8 (R8) as residing at facility prior to or around the time of complaint initiated. As a result, there is no evidence at this time which can corroborate the occurrence of staff neglect of R8.
*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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-20221107142123

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 02/19/2025

NARRATIVE

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#2 Staff handled resident in a rough manner - Based on interviews. Resident #9 (R9) was unable to recall the incident, therefore LPA cannot corroborate if the alleged incident happened. Additional interview with witnesses and the alleged perpetrator were unable to be conducted at this time due to unavailability.

#3 Staff are not properly mitigating the scabies outbreak at the facility - Based on interview and file review, the facility provided the paperwork of the necessary steps that they did to mitigate the scabies outbreak. They provided all the communication/paperwork to the dermatologist, nurses, and other responsible parties. They provided the sanitation procedure/schedule that they did to control the spread and prevention of the outbreak from coming back.

#4 Facility's laundry machine is in disrepair - Based on interview and observation, the facility has laundry machine on each cottage and if one laundry machine is out and not working, they can use the other washing machine from other cottages or the main one in the maintenance room. According to information received, there has not been interference with laundry service for residents.

#5 Staff did not inform resident's authorized representative of resident's incident - Based on staff interview, 6 out of 6 staff stated that every time there is an incident in the facility, they immediately let the nurse know (if there is an injury), the Resident Care Coordinator and Executive Director and they in turn inform the responsible parties. They also send the Special Incident Report (SIR) to Community Care Licensing. Information received during investigation did not corroborate that reports have not been provided to resident’s representative as required.

During the investigation, LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099, LIC909C were discussed and provided to Executive Director Eva Tawfik

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

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