374603735-1-20-2021-08-AS-IESA-BZGSH2-20210326135250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603735
Report Date: 01/20/2021
Date Signed: 01/20/2021 03:28:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/06/2019 and conducted by Evaluator Jonathan C Pineda

COMPLAINT CONTROL NUMBER: 08-AS-20191206170006

FACILITY NAME:	PACIFICA SENIOR LIVING OCEANSIDE		FACILITY NUMBER:	374603735
ADMINISTRATOR:	JONETTA EADS		FACILITY TYPE:	740
ADDRESS:	5508 AVENIDA PACIFICA WAY		TELEPHONE:	(760) 618-5608
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	165	CENSUS: 109	DATE:	01/20/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jackie Banks, Executive Director.		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not conduct welfare checks as required which resulted in a delay of medical care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jonathan Pineda conducted an unannounced complaint tele-visit to deliver findings on the above allegation. The visit was conducted via a tele-visit due to COVID-19. LPA identified himself to Jackie Banks, Executive Director and stated the purpose of the visit.

The Department's investigation consisted of a tour of the facility, observations, interviews with staff, residents, outside sources, and a review of resident’s records, medical records, and hospital emergency records.

It was alleged that the facility did not conduct welfare checks as required which resulted in a delay of medical care. A review of Resident 1’s (R1) (See Confidential Names List) Physician’s Report dated November 8, 2019 and Resident Assessment, dated November 12, 2019 revealed R1 is determined to be independent, not requiring assistance with activities of daily living.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

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 08-AS-20191206170006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374603735
	VISIT DATE: 01/20/2021

NARRATIVE

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Interview with the Administrator revealed facility protocol requires R1 to check in every morning while at the facility by pushing a button in their room. When a resident does not check in by 10:30 AM, assigned staff are required to check records to see if the resident left the facility (check in/out list, vacation, out of community overnight, etc.). If the resident has not left the facility, assigned staff are required to notify a caregiver to conduct a welfare check in-person. Records obtained revealed R1 last checked in on December 1, 2019 at 6:13 AM. R1 did not check-in on December 2, 2019 and December 3, 2019. Welfare checks of R1 were not conducted on December 2, 2019 and December 3, 2019. Interviews revealed that facility staff who were responsible for reviewing the “check-in” list and notifying caregivers to conduct a welfare check with residents lied about seeing R1 during mealtimes on December 2, 2019 and December 3, 2019. Review of video camera concurred that the resident was not present in the dining room during mealtimes on those dates. Responsible staff did not report that R1 did not check in on December 2, 2019. Interviews and record review revealed facility staff falsified the “Assisted Living Dining Check-in Report” on December 3, 2019 by signing their initials next to R1’s name indicating R1 was accounted for.

Investigation revealed on December 1, 2019 at an unknown time, R1 was bending over putting something away in their drawer. R1 turned around, lost their balance, tripped on a rug, and fell on their side. R1 had recently showered and removed their call pendant and was unable to call for help. Interview revealed they were experiencing pain and were unable to stand up. R1 waited for help and assumed staff would come to check on them the next day because their “check in” button was not pushed. R1 yelled for help and no staff came. While waiting for help, R1 soiled the carpet and felt dehydrated. On December 4, 2019, R1 decided to scoot slowly to the phone across the room and call for help. R1 called the front desk at approximately 10:00 AM. Facility staff called 911 and R1 was transported to the hospital. A review of R1’s hospital emergency records revealed R1 sustained a left femoral fracture, pressure injury in coccyx sacral region, and left elbow wound.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20191206170006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374603735
	VISIT DATE: 01/20/2021

NARRATIVE

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The Department investigated the allegation that the facility did not conduct welfare checks as required which resulted in a delay of medical care. Based on a review of records, staff and resident interviews, outside sources, and observations, facility did not conduct welfare checks for approximately 48 hours resulting in a delay of medical care for R1. It is determined that the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D.

Determination of Civil Penalties under Health and Safety Code Section 1569.49 is pending and under review by the Program Administrator of the Community Care Licensing Division.

An exit interview was conducted with Administrator via tele-visit. A copy of this report LIC 9099, LIC 9099 D, along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director, Jackie Banks via email. An electronic email read receipt confirms the documents were received.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20191206170006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374603735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/21/2021 Section Cited CCR 87101(c)(3)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision…the facility assumes responsibility…provides…assistance…without which the resident’s physical health…safety, or welfare would be endangered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to obtain 2 staff signatures every morning after the resident “check in” list is printed and reviewed to ensure resident safety. Licensee will maintain a printed copy of the daily “check in” list. Licensee will provide staff training on procedure to ensure resident safety.
	8 9 10 11 12 13 14	Based on interviews, record review, and observations, Licensee did not conduct welfare checks as required for R1 for approximately 48 hours resulting in a delay of medical care. This posed an immediate health risk to the resident in care.	8 9 10 11 12 13 14	Licensee will provide LPA documentation and proof of training by February 1, 2021 to clear the POC. Determination of Civil Penalties under Health and Safety Code Section 1569.49 is pending and under review by the Program Administrator of the Community Care Licensing Division
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Denise Powell	TELEPHONE: (610) 301-9770
LICENSING EVALUATOR NAME: Jonathan C Pineda	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021

LIC9099 (FAS) - (06/04)

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