336425840-6-26-2024-56-AS-EMAN-D9HQJK-20240927121245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 06/26/2024
Date Signed: 06/26/2024 05:30:28 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
01/26/2024 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240126151948

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: 65	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	04:10 PM
MET WITH:	Julie Shevette		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that resident's dental needs are met.
Staff do not ensure that resident is administered their medications as prescribed.
Staff do not ensure that the facility is clean.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Sales Director Julie Schevette and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour.

For the allegation, Staff do not ensure that resident's dental needs are met.

LPA conducted 7 staff interviews. 7 out of the 7 staff stated dental services are being provided to their residents. 5 out of the 7 staff informed LPA that occasionally residents will refuse to brush their teeth due to behaviors.

During the residents’ interviews, LPA Rico did not find evidence to corroborate the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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 2

Control Number 56-AS-20240126151948

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: 06/26/2024

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

For the allegation, Staff do not ensure that resident is administered their medications as prescribed.

During staff interviews, 7 out of the 7 staff stated all residents receive their medications as prescribed. 4 out of the 7 staff informed LPA that they will document when residents refuse their medications.

During record review LPA discovered that R1 had received all medications. LPA also noted R1 refusals were also documented.

During the residents’ interviews, LPA Rico did not find evidence to corroborate the allegation.

For the allegation, Staff do not ensure that the facility is clean.

During staff interviews, 7 out of the 7 staff indicated the facility is clean. In addition, all staff members informed LPA that they will clean residents’ room every day when they wake.

During facility tour, LPA observed facility to be clean and residents’ bedrooms/bathrooms.

Based on evidence obtained during the investigation, the allegations (3) listed above is deemed 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.

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

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2