374603451-7-21-2023-18-AS-RSTS-CV8VU4-20230831164408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 07/12/2023
Date Signed: 07/21/2023 09:58:03 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE 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
07/03/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230703125256

FACILITY NAME:	PACIFICA SENIOR LIVING ESCONDIDO		FACILITY NUMBER:	374603451
ADMINISTRATOR:	AMY BANAGA		FACILITY TYPE:	740
ADDRESS:	1351 E WASHINGTON AVE		TELEPHONE:	(760) 741-3055
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	143	CENSUS: 110	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Shawna Emery, Resident Care Coordinator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident's room is unsanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility in initiate an investigation into the allegation listed above. LPA met with Resident Care Coordinator Shawna Emery and Marketing Director Carline Callaghan. Executive Director Amy Banaga was off duty at the time of the visit.
During today's visit, LPA toured room #129, interviewed Resident #1 (R1), four (4) staff and reviewed pertinent documents related to R1. Upon tour of R1's room, #129, the room was observed to have an overwhelming odor of dog urine. Dog feces was observed scattered on the carpet of the room as well. Partially consumed drinks and plates of food were observed on the bed where R1 was laying as well as on the floor and desk next to the bed. A half eaten hamburger was on the floor at the foot of the bed. LPA also observed R1's dog eating from a bowl on the bed as well. The patio sliding door was observed open approximately 6 to 8 inches allowing flies to enter the room. The patio was covered in multiple piles of dog feces. A pile of feces soiled wet clothing was observed next to the trash can. LPA observed feces on the bedsheet next to and behind R1's head as they laid in bed. The seat on R1's wheelchair was also covered in dried feces. The tread on the wheels of R1's motorized wheelchair was impacted with dog feces as well. LPA observed R1's (CONTINUED ON LIC9099C) *This is an amended report.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

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-20230703125256

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING ESCONDIDO	FACILITY NUMBER: 374603451
	VISIT DATE: 07/12/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
the toilet to be full of feces, urine, and toilet paper and the back of the toilet seat was covered in either feces or vomit. Review of R1's Admission Agreement (AA) dated 9/22/2020 revealed R1 was to be provided weekly housekeeping of their assigned room and R1 agreed to keep their room in a clean an sanitary condition. The AA also indicated R1 agreed to be responsible for the care and maintenance of their pet. During an interview with R1, R1 stated they believed their assigned weekly housekeeping day was Friday. R1 reported their room is cleaned every week by Maintenance Director Roy Hayes. R1 also reported that there was nothing wrong with their room and did not smell any odor or see any dog feces on the floor. Review of R1's Resident Assessment dated 9/27/2022 revealed R1 was determined to be at care level 1, meaning they were to only receive assistance with medications however, R1 refused to sign the assessment and therefore does not currently receive medication assistance. The assessment also revealed R1 was independent with bathing, grooming, and toileting. The assessment does not indicate the facility is responsible for cleaning up after R1's dog. Review of R1's Physician's Report (PR) dated 4/18/2019 revealed R1 does not have dementia or MCI, is not confused, does not display inappropriate or aggressive behavior, is able to follow instructions and able to communicate their needs. The PR also revealed R1 maintains the capacity to provide self care and manage medications. Further review of R1's records revealed R1 was served with a 30 Day Termination and Notice to Quit on April 25, 2023 for failing to comply with the facility's pet policy regarding the care and maintenance of their pet. During R1's interview, R1 acknowledged receiving an eviction notice for failing to clean up after their pet but added that they did not think it was necessary because there was no issue with their room. Review of housekeeping checklists for R1's room dated Thursday, June 29, 2023 and Thursday, July 6, 2023 revealed R1 refused housekeeping services on those days. Additionally, after receiving complaints from other residents of odor emanating from R1's room, housekeeping was attempted on Tuesday, April 4, 2023, Wednesday, April 5, 2023, and Tuesday, April 25, 2023 and R1 refused each of these attempts.
Four (4) of four (4) staff interviewed revealed R1's weekly housekeeping day is Thursday and R1 regularly declines the service or asks that it be completed at a later time however, when staff return at the requested time, R1 will decline.
This agency has investigated the complaint alleging "Resident's room is unsanitary". 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 and copy of this report was provided along with LIC811- Confidential Names list. *This is an amended report.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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