336425840-11-2-2021-18-AS-EMAN-CA4SC4-20211227124451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:51:33 PM

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
09/16/2020 and conducted by Evaluator Jennifer Semin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200916130024

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: 84	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Usman Chaudary		TIME COMPLETED:	04:06 PM

ALLEGATION(S):

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Facility staff do not allow resident to permanently leave the facility
Facility staff do not allow resident to receive medical treatment by a physician of their choosing
Facility staff failed to assist resident with their broken personal items
Facility staff do not allow resident to have a cell phone or a computer
Facility staff do not allow the resident to receive phone calls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings on the above complaint allegations. LPA met with Resident Care Director, Usman Chaudary. Administrator, Eva Tawfif arrived during the visit.
The investigation consisted of staff and relevant party interviews and review of resident’s record. The first allegation, Facility staff do not allow resident to permanently leave the facility. Staff interviews revealed residents are free to leave and choose another place of residence if they and their responsible party decide to find another place to reside. Resident 1 (R1) was unable to answer the question coherently.
The second allegation, Facility staff do not allow resident to receive medical treatment by a physician of their choosing. Staff interviews revealed that the resident and responsible party are free to choose who their doctor is. Staff stated they have changed R1’s doctor per request but R1 does not recall the change. R1 stated they do not have any doctors, but records revealed multiple visits with multiple disciplines. Relevant party (RP) stated R1’s doctor was changed per R1 and RP request.
The third allegation, Facility staff failed to assist resident with their broken personal items. Staff interviews

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20200916130024

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: 11/02/2021

NARRATIVE

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revealed that resident’s personal items are sent out to be repaired if possible or new appointments are made to replace broken items. R1 stated they do not recall having broken eyeglasses or broken hearing aids. LPA observed R1 to have eyeglasses but not hearing aids. Staff and RP stated RP is working on financing for hearing aids.
The fourth allegation, Facility staff do not allow resident to have a cell phone or a computer. Staff interviews revealed that although most residents do not own cell phone or computers, they can have personal cell phones and a computer, however most residents are unable to use such devices without assistance. R1 stated they can use the phone but do not have anyone to call. RP stated R1 does not know how to use a cell phone.
The fifth allegation, Facility staff do not allow the resident to receive phone calls. Staff interviews revealed staff allow residents to receive phone calls. R1 stated R1 talks to family members on the phone. RP stated they talk to R1 on the phone.
Based on interviews and documents reviewed and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was discussed and provided to Mr. Chaudary

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer Semin	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

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