336425840-1-22-2025-56-AS-KCLS-DDESGZ-20250130125246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 01/22/2025
Date Signed: 01/22/2025 02:06:35 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2025 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20250117145104

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: 79	DATE:	01/22/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained unexplained injuries in care
Facility staff handled resident in a rough manner
Facility spoke inappropriately to resident
Facility staff did not follow hospice care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Tawfik and explained the elements if the complaint.

Allegation #1, LPA interviews with staff #1 (S1) and staff #2 that reveals resident #1 (R1) sustained an injury due a fall. The fall was documented and R1's responsible party was notified as well as R1's Hospice representative. LPA interviewed R1, who stated that the injury was caused by herself when R1 attempted to stand from a seated position. R1 indicated what the injuries were and that the injuries were treated. The fall was witness by resident #2 (R2), who concurred R1's description of the fall.

Allegation #2, the allegation of "facility staff handled resident in a rough manner", stems from the transfer of R1 from her wheelchair to the bed by staff. LPA interviewed S1 who indicated R1 was tranferred properly to the bed. Confirmation of the proper transfer was concurred by S2, Memory Care Director.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

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-20250117145104

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
, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 01/22/2025

NARRATIVE

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R1 was interviewed by LPA and stated that she was not treated in a rough manner during transfers by staff.
Allegation #3, the allegation was made relating to instructions made to R1 during a transfer by staff. Staff spoke to R1 in a loud tone of voice because R1 is hard of hearing. S1 heard these instructions and assisted caregiver during this transfer. S1 confirmed that R1 is hard of hearing. LPA interviewed R1 who confirmed she is hard of hearing. R1 also stated that she only wears her hearing aids when she is visited by her responsible party.

Allegation #4, stems from the allegation that R1's air mattress is not properly inflated. This bed was prescribed by the Hospice Agency and has an electronic monitor. S1 interview states the monitor appears to by faulty and called the Hospice Agency to either replace monitor or observe mattress for leaks. This device is provided by the Hospice agency who is responsible for the device to work properly.

Based on the information obtained there is not enough evidence that resident sustained unexplained injuries in care, facility staff handled resident in a rough manner, facility spoke inappropriately to resident and facility staff did not follow hospice care plan. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Tawfik and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025

LIC9099 (FAS) - (06/04)

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