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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603735
Report Date: 05/31/2024
Date Signed: 06/13/2024 09:19:50 AM

Unsubstantiated


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
10/06/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20201006153042
FACILITY NAME:PACIFICA SENIOR LIVING OCEANSIDEFACILITY NUMBER:
374603735
ADMINISTRATOR:JONETTA EADSFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 618-5608
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:0CENSUS: 0DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:TIME COMPLETED:
09:44 AM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes provided the complaint report via mail to the last recorded address on file.

The inital investigation visit was on 10/14/2020, the visit consisted of tour of the facility, conducting interviews and reviewing facility records. The complaint alleges that the death of a resident was questionable. The investigation revealed that Resident 1 (R1) was a resident at the facility from March 15,2019 until their death on September 29, 2020. R1 did not have multiple health concerns that were identified by R1’s physician report. Interviews revealed that R1 had an unwitnessed fall on September 28, 2020, staff responded around 2:37pm and found the resident on the floor.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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 4
Control Number 08-AS-20201006153042
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: PACIFICA SENIOR LIVING OCEANSIDE
FACILITY NUMBER: 374603735
VISIT DATE: 05/31/2024
NARRATIVE
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Interviews revealed that when R1 was asked R1 stated they did not have any pain or discomfort. It was noted that R1 had no bruising on body except to the left eye. Interviews revealed that around 4:50 pm staff responded to R1's room and took R1 to the restroom via a wheelchair. It was during that time that R1 stated "my legs are not helping and I'm scared of falling". Interviews revealed that hospice was called around 2:40pm. Hospice called the family around 6pm when they arrived at the community. While hospice was there they reviewed the medication list and updated it. Interviews revealed medications were ordered. Interviews revealed when R1 was admitted to hospice with a diagnosis of End Stage Moderate Protein Deficiency. During hospice visit it was observed that resident was showing signs of decline. R1's death certificate stated the immediate cause of death was due to Atherosclerotic Cardiovascular Disease. There is insufficient evidence that the facility contributed to R1’s death.

The investigation did not produce supporting evidence or supporting witness statements to substantiate. Based on the evidence obtained from interviews, and record review, the complaint allegation is unsubstantiated.

LPA Holmes mailed a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) to the last mailing address on file.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/06/2020 and conducted by Evaluator Tiffany Holmes
COMPLAINT CONTROL NUMBER: 08-AS-20201006153042

FACILITY NAME:PACIFICA SENIOR LIVING OCEANSIDEFACILITY NUMBER:
374603735
ADMINISTRATOR:JONETTA EADSFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 618-5608
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:0CENSUS: 0DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:TIME COMPLETED:
09:44 AM
ALLEGATION(S):
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Licensee did not report changes in resident's medical condition to resident's responsible person.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tiffany Holmes provided the complaint report via mail to the last recorded address on file.

The inital investigation visit was on 10/14/2020, the visit consisted of tour of the facility, conducting interviews and reviewing facility records. The complaint alleges that the licensee did not report changes in resident's medical condition to resident's responsible person. Interviews revealed that Resident 1 (R1) was the one that called their family. Interviews revealed the facility called hospice at around 3pm. The facility did not call the responsible party or family regarding R1. The investigation revealed that (R1) refused to go to the hospital and they reminded them that they had a pendant on which interviews revealed R1 forgot they had it on. Interviews revealed no one assisted R1 until about 5pm which was when the family called the facility and the facility then let the family know about R1.

Based on interviews the above allegation is substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency is cited per Title 22 California Code of Regulation. LPA Holmes mailed a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) to the last mailing address on file.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20201006153042
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: PACIFICA SENIOR LIVING OCEANSIDE
FACILITY NUMBER: 374603735
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
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Facility is closed
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Based on interviews the licensee did not report incident for 1 out of 109 residents in care [R1] which poses a potential health and safety risk.
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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: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4