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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 372008448
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:21:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240808115635
FACILITY NAME:CASA PACIFICAFACILITY NUMBER:
372008448
ADMINISTRATOR:LISA DIAZ DUFACILITY TYPE:
772
ADDRESS:321 CASSIDY STREETTELEPHONE:
(760) 721-2171
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:14CENSUS: 14DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Assistant Program Director Shelzea FelixTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee did not provide a 30 day eviction notice
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Assistant Program Director Shelzea Felix

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources, including staff.

It was alleged Licensee did not provide a 30-day eviction notice. It was reported the Department Client #1 (C1) left the facility (Absent Without Official Leave) on July 9th, 2024, was out of the facility for approximately three weeks before being admitted to a local hospital. When the hospital attempted to discharge C1 back to the facility, the facility management declined to readmit C1.

(See LIC 9099C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 3
Control Number 08-AS-20240808115635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA PACIFICA
FACILITY NUMBER: 372008448
VISIT DATE: 09/27/2024
NARRATIVE
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Interviews with facility staff, and review of records confirmed C1 left the facility on July 9th, 2024, was considered AWOL, and the facility considered C1 to be discharged from the facility after seven days of no contact. It was also revealed C1 was conserved through the San Diego Office of the Public Conservator. Throughout the investigation, facility management indicated multiple employees from the San Diego Office of the Public Conservator had approved C1’s discharge from the facility and provided the LPA email communication. Review of the email communication and interviews with Office of the Public Conservator employees, revealed the facility informed the Office of the Public Conservator of the discharge, not that the Office of the Public Conservator had approved the discharge.

Although the facility and Office of the Public Conservator noted the treatment provided to C1 was voluntary and treatment could be refused by C1, there was no evidence that C1 declined, nor refused treatment the day C1 left the facility. Based on the evidence obtained, the facility did not provide a 30-day eviction notice as indicated in the California Code of Regulations. This deficiency was cited in an LIC 9099D form and a Plan of Correction was jointly formulated with Shelzea Felix.

An exit interview was conducted with Felix, to whom a copy of this report, LIC 9099D, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240808115635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CASA PACIFICA
FACILITY NUMBER: 372008448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
81068.5(a)
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81068.5 Eviction Procedures (a) The licensee shall be permitted to evict a client with 30 days' written notice for any of the following reasons:

This requirement was not met as evidenced by:
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Assistant Program Director agreed to provided eviction procedure training to clinicians and management, by 10/25/2024.

A log noting who attended will be provided to the LPA by 10/25/2024.
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Based on review of records, and interviews, the licensee did not ensure the facility provided a 30 day eviction notice to C1, which posed a potential health, safety, and personal rights rights to1 of 14 clients in care.
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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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3