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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 03/09/2020
Date Signed: 10/20/2021 09:10:06 AM



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
03/04/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200304144916
FACILITY NAME:PACIFICA SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:92CENSUS: 78DATE:
03/09/2020
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Usman ChaudaryTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Facility failed to make records available to resident upon request
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate an investigation and deliver the finding on the above complaint allegation. LPA met with Memory Care Diirecor, Usman Chaudary and spoke with Executive Director, Eva Tawfik via telephone.

LPA conducted interviews with relevant parties. LPA recieved a letter on 3/11/2020 from the reporting party indicating a formal withdrawal.

Based on this information, 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.

An exit interview was conducted where this report was discussed and provided to Ms. Tawfik.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 18-AS-20200304144916
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
03/13/2020
Section Cited
HSC
1569.269(21)
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made in error
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made in error
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2