374604134-6-11-2025-18-AS-APEZ-DHPTGE-20250616144301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 06/11/2025
Date Signed: 06/11/2025 07:11:57 PM

Unsubstantiated

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
03/15/2024 and conducted by Evaluator Yolanda Delgado

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240315160442

FACILITY NAME:	PACIFICA SENIOR LIVING VISTA		FACILITY NUMBER:	374604134
ADMINISTRATOR:	ENCISO, KAREN		FACILITY TYPE:	740
ADDRESS:	760 EAST BOBIER DRIVE		TELEPHONE:	(760) 941-1480
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	172	CENSUS: 83	DATE:	06/11/2025
		UNANNOUNCED	TIME BEGAN:	06:35 PM
MET WITH:	Beatrice Pena, Med Tech		TIME COMPLETED:	07:20 PM

ALLEGATION(S):

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Staff neglect resulted in resident sustaining two head injuries
Staff neglect resulted in resident sustaining multiple falls
Staff did not assist resident with dental hygiene as needed
Staff did not provide copy of written admission agreement to resident's responsible person at admission
Staff retained a resident beyond their scope of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Beatrice and explained the purpose of the visit. Executive Director Diane Domingo was contacted by telephone.

On March 15, 2024, Community Care Licensing received a complaint alleging neglect resulted in resident sustaining two head injuries and staff neglect resulted in resident sustaining multiple falls, staff did not assist resident with dental hygiene as needed, staff did not provide a copy of written admission agreement to resident’s responsible person at admission, staff retained a resident beyond their scope of care. LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) to obtain pertinent information due to R1 no longer living at the facility since February 28, 2024. R1’s spouse confirmed that R1 passed away on November 3, 2024.
(Continued on Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

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-20240315160442

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 VISTA	FACILITY NUMBER: 374604134
	VISIT DATE: 06/11/2025

NARRATIVE

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(Continued from Page 1)

Regarding the allegation resulted in resident sustaining two head injuries and staff neglect resulted in resident sustaining multiple falls, it was reported that between December 28, 2023, through February 8, 2024, R1 had ten incidents that included falls. R1 was admitted as a fall risk and had an unsteady gait. It was recommended that R1 use a walker. Information obtained from interviews stated R1 did not like to use the walker, and it was also advised that R1 would wander through the facility at night without their walker. R1 had a total of five falls where R1 was found on the side of the bed on the fall mat or found sliding off own bed onto the fall mats, one fall in the dining room where R1 slid off own wheelchair, and the last fall witnessed by R1’s spouse coming out of the bathroom and observed R1 attempting to get up from wheelchair and fell forward. One incident, R1 was walking in the hallway without walker, and feet got crossed causing to trip and fall hitting head, staff assessed and immediately called 911 and another incident, staff witnessed R1 in the dining room where R1 was agitated and threw body forward on wheelchair causing head to hit the floor, staff assessed and immediately called 911. Hospice documents reviewed revealed a low ground hospital mattress, halo rails and fall matt were in placed along with a walker and a wheelchair, due to R1’s anxiety and agitation, medication were noted to be ineffective by hospice.

Regarding the allegation staff did not assist resident with dental hygiene as needed, it was reported that R1 sustained a mouth infection due to staff not taking his partial out when brushing his teeth. Based on staff and resident interviews it was revealed residents are helped by staff according to their needs. A review of facility records, R1’s needs and services plan dated December 28, 2023, requested assistance with personal hygiene for dental care, in which it was provided by staff.

Regarding the allegation staff did not provide a copy of written agreement to resident’s responsible person at admission, it was reported requested and just now provided. Based on staff and resident interviews it was revealed residents and their responsible parties are provided a copy of written agreements. A review of facility records did reveal R1’ responsibility party signed documents December 19, 2023.

(Continued on Page 3)

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240315160442

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 VISTA	FACILITY NUMBER: 374604134
	VISIT DATE: 06/11/2025

NARRATIVE

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(Continued from Page 2)

Regarding the allegation staff retained a resident beyond their scope of care, it was reported the facility neglected to meet R1’ needs as a fall risk. Based on staff and residents interviews it was revealed that the facility took all precautions to prevent falls risks. A review of facility records, R1 was on hospice and a care meeting involved R1’S responsible party, hospice agency and facility to assist R1 with additional services and there were many fall precautions and prevention strategies put in place for R1 during the time frame at the facility.

Based on staff interviews, witness interview, hospital records, facility records, the allegation Neglect Lack of Care and supervision resulted in resident sustaining multiple falls and Neglect Lack of Supervision resulted in resident sustaining two head injuries, staff did not assist resident with dental hygiene as needed, staff did not provide a copy of written admission agreement to resident’s responsible person at admission, staff retained a resident beyond their scope of care is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Beatrice Pena and Diane Domingo by telephone and a copy of this report along with LIC811- Confidential Names list was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025

LIC9099 (FAS) - (06/04)

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