336425840-8-26-2021-18-AS-TDAN-D4FTSG-20240418145907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:05:00 AM

Unfounded

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/24/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210524131231

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: 83	DATE:	08/26/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Eva Tawfik - Executive Director		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident sustained fracture while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin arrived to deliver findings for the allegations of the complaint. LPA Colvin met with Executive Director/Administrator Eva Tawfik and advised Eva of the purpose of the visit.

Regarding allegation "Resident sustained fracture while in care": The Department conducted interviews and reviewed documents from the facility and outside medical providers regarding resident's (R1) right wrist fracture, for which R1 was seen by an Orthopedic Surgeon on 5/19/21 and fitted with a cast. Through investigation of this complaint, LPA Colvin confirmed that R1 had a fall on 5/7/21, which was witnessed by staff, and the facility staff immediately contacted R1's Home Health nurse for evaluation. Through the Home Health agency, R1's wrist was X-rayed at the facility on 5/11/21. After review of X-rays showed that R1 had evidence of a fractured wrist, facility staff followed up with calling R1's primary care physician (PCP) the following day. R1 was referred by their PCP to an orthopedic surgeon, who was unable to see R1 until 5/18/21 due to that being the next available appointment. At R1's appointment with the orthopedic surgeon, R1's fractures wrist was secured by a cast and an additional follow-up appointment was scheduled.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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-20210524131231

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
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 08/26/2021

NARRATIVE

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While the investigation of this complaint confirmed that R1 sustained a fracture at the facility, a review of the evidence shows that the facility staff took the necessary steps to obtain medical care for R1, such as contacting Home Health, getting an X-ray completed, and having R1 seen by an orthopedic surgeon. The facility staff continued to follow-up to ensure R1 received prompt medical attention by having R1 taken to the Emergency Room after R1 removed their cast.

Therefore, based on interviews and record review, the allegation of "Resident sustained fracture while in care" is UNFOUNDED. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Executive Director Eva Tawfik and a copy of this report was provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC9099 (FAS) - (06/04)

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