336425840-11-2-2023-18-AS-EMAN-CY3QK3-20231130111339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:47:53 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
08/13/2020 and conducted by Evaluator Ryan Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200813151731

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: 86	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Eva Tawik- Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff failed to provide resident food.
Resident suffered from dehydration while in care.
Facility failed to observe resident's change in condition.
Staff failed to meet the resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director Eva Tawfik. The investigation consisted of resident interviews, staff interviews, and document review.

For allegation, Staff failed to provide resident food:

Interviews with residents and the staff revealed that the residents are provided with food. The staff denied not providing the residents food. The residents stated that they are provided food throughout the day. The residents are provided three (3) full meals a day and three (3) snacks throughout the day. If a resident is still hungry after their meals and snacks, the residents can request additional food at any point during the day or night. A document review of the facilities menu revealed that the residents are served three (3) meals a day that includes protein, vegetables, fruit, and carbohydrates, as well as snacks throughout the day.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 18-AS-20200813151731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 11/02/2023

NARRATIVE

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During document review of R1’s records, LPA did not find information to collaborate that R1 was not provided food while in care.

For allegation, Resident suffered from dehydration while in care:

Interviews with the residents and the staff revealed that the residents are provided with water and other liquid options throughout the day. The staff denied not providing water and or other liquids to ensure the residents stay hydrated. The residents stated that the staff provided the residents with plenty of water and other liquids to stay hydrated throughout the day. The facility provides a pitcher of water outside each cottage where the residents can access water on their own. If a resident needs assistance getting water from the pitchers, the residents can ask a staff member to bring water to their room or their current location. The facility also provides juice, coffee, milk, and tea as liquid options. During document review of R1’s records, LPA did not find information to collaborate that R1 was dehydrated while in care.

For allegation, Facility failed to observe resident's change in condition:

Interviews with the residents and the staff revealed that the staff checks on the residents frequently throughout the day. The residents are checked on average every thirty (30) minutes to two (2) hours depending on the residents’ needs. The staff denied that they do not observe the changing conditions of the residents’ needs. If a staff notices a change of condition, the change is escalated to the nurse for review. The nurse will analyze the resident and escalate the situation to their doctor, family, and call for emergency medical help if necessary. During document review of R1’s records, LPA did not find information to collaborate that R1 had a change in condition that was not observed.

For allegation, Staff failed to meet the resident's needs:

Interviews with the residents and the staff revealed that the staff are meeting the needs of the residents. The staff denied not meeting the needs of the residents. The residents stated that the staff is very caring, and the staff helps them with their daily needs. During document review of R1’s records, LPA did not find information to collaborate that R1’s needs were not being met.

Overall, there was not enough evidence to collaborate the allegations listed above.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200813151731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 11/02/2023

NARRATIVE

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Based on evidence obtained during the investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Executive Director Eva Tawfik, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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