336425840-12-31-2024-56-AS-KCLS-DCH2Q9-20241231163535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 12/13/2024
Date Signed: 12/31/2024 10:26:23 AM

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
11/19/2024 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20241119202411

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: 73	DATE:	12/13/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Eva Tawfix, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Resident sustained multiple falls due to lack of care or supervision from staff.

INVESTIGATION FINDINGS:

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**This is an amended copy. Original 9099 signed and dated on 12/13/2024**
On 12/13/2024 at 1:25 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 a staff. Staff informed the Executive Director (ED) Eva Tawfik of the visit. ED met with LPA Serrano and LPA explained the purpose of the visit to ED Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation.

The investigation was conducted by LPA Serrano. The investigation consisted of records review and interviews with relevant parties. The allegations indicate:

#1 Resident sustained unexplained injuries while in care – Based on residents and staff interview, 6 out of 6 residents and 5 out of 6 staff stated that they did not witness or observe any resident that sustained unexplained injuries while in care at the facility.
*** Continuation in LIC9099C ***.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

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-20241119202411

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: 12/13/2024

NARRATIVE

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1 staff (Staff 3) indicated that resident #1 (R1) hands were lightly bruised in the morning because of the staff trying to restrain R1 and prevent R1 from hitting the staff. However, the lightly bruising was not because of abuse but by R1 skin being sensitive. This happened about a year ago and Staff 3 did not notice any bruising lately.

#2 Resident sustained multiple falls due to lack of care or supervision from staff - Based on residents and staff interview, 6 out of 6 residents and 5 out of 6 staff stated that they did not witness or observe any resident sustained multiple falls due to lack of care and supervision from staff. 1 staff (Staff 2) stated that they were some fall incidents, however it was not due to lack of supervision or care but by the resident’s medical condition like Parkinson’s disease.

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 allegation is unsubstantiated at this time.

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

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin Serrano	TELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024

LIC9099 (FAS) - (06/04)

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